TO A LARGE EXTENT, American society has made gay men and lesbians the brunt of multiple levels of prejudice, with negative assumptions about their morality, trustworthiness, employability, and integrity. (Similar accusations have been made against African-Americans, Jews, and other ethnic groups.) As a result, gay men and lesbians developed a hidden subculture among themselves that only recently has become much more open, and now weaves throughout all segments of society. Surveys of the homosexual community suggest that medical practitioners may lack knowledge of the issues salient in the lives of gay men and lesbians and inadvertently and sometimes purposely have alienated their patients. The gay and lesbian community is much more visible today and is asking for health care that recognizes its unique medical demographic profile and is provided with the same degree of knowledge, sensitivity, and respect afforded other segmeets of America's large and diverse society. Homophobia is defined as the "unreasoning fear of or antipathy toward homosexuals and homosexuality." It operates on two levels: internally and externally. internal homophobia represents prejudices that individuals incorporate into their belief systems as they grow up in societies biased against gays and lesbians. External homophobia is the overt expression of those biases, ranging from social avoidance to legal and religious proscription to violence.
There is no scientific basis for homophobic prejudice. The initial classification of homosexuality as a mental disorder in the Diagnostic and Statistical Manual (DSM-III) has been reviewed extensively and found to be reflective only of the social mores at the time it was inserted. The extensive psychiatric literature reveals no major differences in levels of maturity, neuroticism, psychological adjustment, goal orientation, or self-actualization between heterosexuals and homosexuals. A few studies, though, have revealed slightly higher lifetime rates of depression, attempted suicide, psychological help seeking, and substance abuse among the latter. These rates are attributed to the chronic stress from the endurance of societal hatred or the ascription of inferior status. This stress may have worse mental health implications than other stressors because of the frequent loss of familial support systems and the concealment and suppression of feelings and thoughts.
The developmental steps gay men and lesbians must negotiate helps explain the psychological injury to which they are vulnerable. These include recognizing and accepting their homosexual orientation despite pervasive familial and societal condemnation; developing a new identity as a gay/lesbian person, a process labeled "coming out"; and confronting ubiquitous homophobia.
Children, sometimes as young as two to eight years old, who experience homosexual feelings often are isolated and alienated from family members who perceive that heterosexuality is the only acceptable "norm." In American society, some religious organizations promote homophobia by depicting homosexuality as an immoral proclivity that must be resisted, often telling gay and lesbian children they are wicked and condemned to hell. Educational institutions do not teach children about diversity of orientation, particularly at the ages when most youths begin to discern their orientation. The paucity of gay and lesbian role models in society, combined with negative stereotypes in the media, further diminishes the ability of gay and lesbian youth to develop a positive self-identity and gain respect and understanding from their peers.
The Committee on Adolescence of the American Academy of Pediatrics acknowledged in 1993 that gay and lesbian youth, while attempting to reconcile their feelings with negative societal stereotypes, confront a "lack of accurate knowledge, [a] scarcity of positive role models, and an absence of opportunity for open discussion. Such rejection may lead to isolation, run-away behavior, homelessness, domestic violence, depression, suicide, substance abuse, and school or job failure. …