“I Have No Idea What's Going On Out There:” Parents' Perspectives PDF

Sexuality Research and Social Policy (2018) 15:111–122 https://doi.org/10.1007/s13178-018-0326-0 BI Have No Idea What’s Going On Out There:^ Parents’ Perspectives on Promoting Sexual Health in Lesbian, Gay, Bisexual, and Transgender Adolescents Michael E. Newcomb 1,2 & Brian A. Feinstein 1,2 & Marg...

Sexuality Research and Social Policy (2018) 15:111–122 https://doi.org/10.1007/s13178-018-0326-0 BI Have No Idea What’s Going On Out There:^ Parents’ Perspectives on Promoting Sexual Health in Lesbian, Gay, Bisexual, and Transgender Adolescents Michael E. Newcomb 1,2 & Brian A. Feinstein 1,2 & Margaret Matson 1,2 & Kathryn Macapagal 1,2 & Brian Mustanski 1,2 Published online: 26 March 2018 # Springer Science+Business Media, LLC, part of Springer Nature 2018 Abstract Lesbian, gay, bisexual, transgender, and other sexual and gender minority (LGBTQ) adolescents experience higher rates of negative sexual health outcomes relative to their heterosexual and cisgender peers. Healthy parent-adolescent relationships and effective parenting are robust predictors of sexual health in heterosexual adolescents, but very little is known about barriers to and facilitators of effective parenting from the perspective of parents of LGBTQ adolescents. This study conducted online focus groups with 44 parents of LGBTQ adolescents in order to describe the factors influencing effective sexual health communication and parental monitoring in this population. Parents described generally positive relationships with teens, but many noted they went through a transition process in which they struggled with their child’s identity and were less supportive of their LGBTQ teen. Lack of understanding about LGBTQ-specific sexuality was a commonly endorsed barrier to effective communication, and this was most commonly endorsed by parents of cisgender girls. Parents of cisgender boys and transgender/gender- nonconforming teens described fears about long-term sexual health (i.e., sexual predators, consent) as a barrier to parental monitoring. Parents of LGBTQ adolescents need information and skills to optimize their teen’s sexual health. Parent-based programs for LGBTQ adolescents are long overdue for addressing these issues. Keywords LGBT youth. Parent-child relationships. Parenting. Sexual health. HIV/AIDS. Sexual health communication. Parental monitoring Lesbian, gay, bisexual, transgender, and other sexual and gender pregnancy compared to heterosexual women (Kann, Olsen, minority (LGBTQ) adolescents and young adults experience McManus, Harris, Shanklin, Flint, Zaza, 2016; Saewyc, various sexual health inequities relative to their heterosexual Bearinger, Blum, & Resnick, 1999; Saewyc, Poon, Homma, & and cisgender (i.e., nontransgender) peers (Mustanski, Birkett, Skay, 2008). A large body of literature has documented the pro- Greene, Hatzenbuehler, & Newcomb, 2014). Research has ob- motive effects of healthy parent-adolescent relationships and par- served high prevalence and incidence of HIV/AIDS among enting practices on heterosexual adolescent sexual health young men who have sex with men (YMSM) (CDC, 2016) (Dishion & McMahon, 1998; Hawkins, Catalano, & Miller, and transgender women and men (Clark, Babu, Wiewel, 1992), but very little is known about how parents of LGBTQ Opoku, & Crepaz, 2016; Poteat, Scheim, Xavier, Reisner, & youth navigate these issues. Given that LGBTQ youth are at high Baral, 2016). Further, young sexual minority women have lower risk for negative sexual health outcomes and too often experience rates of pregnancy prevention use and higher rates of unintended strained relationships with parents (Bouris, Guilamo-Ramos, Jaccard, McCoy, Aranda, Pickard, & Boyer, 2010), more infor- mation is needed from parents with regard to barriers to and * Michael E. Newcomb facilitators of effective parenting of LGBTQ teens. [email protected] Specific parenting practices that are meant to protect adoles- cents from risky situations and negative health outcomes are 1 Department of Medical Social Sciences, Northwestern University most effective in the context of healthy parent-adolescent rela- Feinberg School of Medicine, 625 N. Michigan Ave., 14-059, tionships (Dishion & McMahon, 1998). LGBTQ youth face Chicago, IL 60611, USA substantial social stress due to their sexual and gender minority 2 Institute for Sexual and Gender Minority Health and Wellbeing, statuses (Hatzenbuehler, 2009; Hendricks & Testa, 2012; Meyer, Northwestern University, Chicago, IL, USA 2003), so the presence and quality of parental support may be 112 Sex Res Soc Policy (2018) 15:111–122 especially critical for buffering these youth against negative are more likely to conceal their dating activities from their health outcomes. Indeed, a handful of studies suggest that lack parents either because they are not out to their parents or they of parental support (e.g., rejection) after coming out (i.e., disclo- worry about how their parents will react to disclosures of sure of LGBTQ identity) may increase the likelihood of engaging same-sex dating. Further, sexual health communication may in condomless anal sex (Ryan, Huebner, Diaz, & Sanchez, 2009) be a less effective parenting practice for LGBTQ adolescents and being diagnosed with HIV or STIs in samples of YMSM if parents (a) are not aware of their child’s LGBTQ identity (Garofalo, Mustanski, & Donenberg, 2008; Glick & Golden, and therefore unknowingly omit LGBTQ-specific informa- 2014). Unfortunately, nearly all existing studies on the influence tion, (b) are not comfortable discussing LGBTQ sexuality of parent-adolescent relationships on health outcomes among and therefore do so less with their teens, or (c) do not have LGBTQ youth utilize samples of older adolescents and young sexual health knowledge specific to LGBTQ sexuality and adults reporting retrospectively on their teenage years, which thus provide these teens with information that is less relevant may lead to recall bias. Further, most studies have focused ex- to their needs. Taken together, the lack of research on the clusively on YMSM, and the health concerns of sexual minority effectiveness of specific parenting practices on LGBTQ ado- women and transgender and gender-nonconforming (TGNC) lescent sexual health is troubling, and parents’ perspectives on youth likely differ from those of YMSM. Finally, prior studies barriers to effective parenting are needed. have largely failed to examine these relationships from the per- Only a handful of studies have examined the effects of spective of parents. Without understanding the perspective of parenting practices on LGBTQ adolescent sexual health out- parents, it would be nearly impossible to develop programs to comes. One recent study analyzed data from three samples of help parents effectively promote healthy sexuality in these youth. YMSM and found that both parental knowledge and monitor- Several reviews of the literature have identified two key ing were associated with less engagement in condomless anal parenting skills that influence heterosexual adolescent sexual sex among YMSM ages 18 and under (Mustanski, Swann, health outcomes: parental monitoring and parent-adolescent Newcomb, & Prachand, 2017). In contrast, Thoma and sexual communication (Kincaid, Jones, Sterrett, & McKee, Huebner (2014) found that parental monitoring actually in- 2012; Wight & Fullerton, 2013). Parental monitoring (i.e., creased engagement in condomless anal sex for YMSM who tracking and enforcing rules) impacts adolescent risk behavior were not out to their parents. These findings indicate that by directly preventing engagement in risk through enforce- parental knowledge and monitoring may be more complex ment of rules and modeling effective self-monitoring strate- among LGBTQ adolescents. If LGBTQ youth mislead their gies (Dishion & McMahon, 1998; Stattin & Kerr, 2000). The parents about their whereabouts for fear of negative repercus- literature often distinguishes parental knowledge of adoles- sions (possibly because they have not disclosed their LGBTQ cents’ activities from the act of parental monitoring (i.e., en- identity to their parents), parents are left with incorrect or forcement of rules), and a recent meta-analysis found that incomplete information, which could render monitoring less parental knowledge was associated with increased condom effective or even damaging. use in samples of presumably heterosexual adolescents while With regard to sexual health communication, there appears parental monitoring was not (Dittus, Michael, Becasen, to be a similarly complex relationship with sexual health out- Gloppen, McCarthy, & Guilamo-Ramos, 2015). Another re- comes among LGBTQ adolescents. Some research has sug- cent meta-analysis found a small association between sexual gested that YMSM who have reduced or strained communi- health communication and sexual risk behavior among pre- cation about sex with their parents engage in more sexual risk sumably heterosexual adolescents (Widman, Choukas- behaviors and are less likely to receive HIV testing (Bouris, Bradley, Noar, Nesi, & Garrett, 2016). Hill, Fisher, Erickson, & Schneider, 2015; LaSala, Siebert, Importantly, neither of these meta-analyses reported sepa- Fedor, & Revere, 2016). Thoma and Huebner (2014), on the rate effects for LGBTQ adolescents, and there is reason to other hand, found that higher levels of parent-adolescent sex- believe that these parenting skills may function differently ual communication were actually associated with more with these youth. First, effective use of parenting skills to condomless sex among YMSM who were out to their parents. promote sexual health hinges on whether teens have disclosed These contrasting findings indicate that the content of conver- their LGBTQ identity to their parents, and many LGBTQ sations about sex may play an important role in the influence teens do not come out to their parents for fear of negative of parent-adolescent communication on sexual health knowl- reactions or rejection (Grafsky, 2017; Savin-Williams & edge, behaviors, and outcomes for LGBTQ youth. However, Ream, 2003). More specifically, parental knowledge and the effectiveness of sexual health communication requires that monitoring are not feasible practices for curtailing sexual risk parents are both aware of their child’s LGBTQ identity and behavior if adolescents conceal certain activities from their have adequate knowledge about LGBTQ sexuality in order to parents (Dishion & McMahon, 1998). As we have found in impart useful information. our prior research (Feinstein, Thomann, Coventry, Only a very small number of studies have been conducted Macapagal, Mustanski, & Newcomb, 2017), LGBTQ youth on these issues from the perspective of parents of LGBTQ Sex Res Soc Policy (2018) 15:111–122 113 adolescents, and these studies have almost exclusively 13–17 years; (3) be able to read and write English; and (4) focused on the experiences of parents of YMSM. In one of have consistent Internet access. Participants were recruited the first studies of parents of LGBTQ youth, Saltzburg (2004) through multiple sources, including social media advertise- found that many parents emotionally detached from their child ment, participant referral, and word of mouth. when they first came out as LGBTQ. Although many of these Advertisements described a university study that aimed to parents described a process through which they eventually better understand issues related to LGBTQ adolescent health became closer to their children by seeking education about and parent-adolescent relationships. The advertisement direct- LGBTQ issues, the period immediately after coming out ed individuals to an online eligibility survey. Those who ap- may be a time during which LGBTQ youth are particularly peared eligible based on their responses were contacted via vulnerable to negative health outcomes. With regard to sexual telephone to confirm eligibility and provide information about health, studies have found that many parents avoid discussing the study. A total of 167 people were eligible, and 48 enrolled sexuality with their gay or bisexual male teens because they in the study (an additional 39 enrolled in focus groups on a are uncomfortable talking about same-sex sexuality (LaSala, different topic with the same eligibility criteria). Of those 48, 2015) or because they lack knowledge about these issues 44 completed at least 1 day of the focus group. See Table 1 for (Rose & Friedman, 2016). However, general perceptions of a summary of the demographic characteristics of this sample. parent-child closeness (as reported by both the parent and Three online focus groups were conducted between April teen) are associated with less sexual risk behavior (LaSala, and May 2016. Focus groups were conducted via online fo- 2007, 2015), indicating that supportive relationships may rums (DuBois, Macapagal, Rivera, Prescott, Ybarra, & buffer against negative sexual health outcomes. Based on Mustanski, 2015; Macapagal, Coventry, Arbeit, Fisher, & these limited data, it is clear that more information is needed Mustanski, 2016). Each focus group was moderated by two from the perspective of parents to better understand barriers to and facilitators of emotionally supportive relationships with Table 1 Demographic characteristics of parents and teens, N = 44 LGBTQ adolescents, as well as the contexts in which parental monitoring and sexual health communication are effective and Demographic characteristic Number Percentage ineffective for promoting LGBTQ adolescent sexual health. Parent gender identity Taken together, the limited existing literature on the influ- Cisgender male 1 2.3 ence of parenting on LGBTQ adolescents has several gaps Cisgender female 42 95.5 that need to be addressed. First, parents’ perspectives on these Genderqueer/gender nonconforming 1 2.3 issues have rarely been considered, and this information is Parent race/ethnicity critical to building interventions that optimize the functioning White 42 95.5 of parent-adolescent relationships. Additionally, the limited Hispanic/Latino 1 2.3 research on these relationships has generally focused on More than one race 1 2.3 cisgender sexual minority boys (or samples described as YMSM), and we need to know more about how parents ad- Parent sexual orientation dress sexual health with cisgender sexual minority girls and Bisexual 5 11.4 TGNC adolescents. The primary goal of the current study was Heterosexual 37 84.1 to conduct online focus groups with parents of LGBTQ youth Other 2 4.5 in order to (a) understand how parents communicate with their Teen gender identity LGBTQ adolescents about healthy sexuality and (b) describe Cisgender male 17 38.6 the strategies parents use to increase their knowledge about Cisgender female 9 20.5 and monitor their LGBTQ adolescent’s dating and sexual Transgender male 9 20.5 behavior. Transgender female 1 2.3 Genderqueer/gender nonconforming 8 20.5 Teen sexual orientation Method Gay/lesbian 22 50.0 Bisexual 10 22.7 Participants and Procedures Queer 5 11.4 Unsure/questioning 5 11.4 Participants were 44 parents of LGBTQ adolescents. In order Heterosexual (same-sex attracted) 2 4.5 to participate, parents had to meet the following criteria: (1) be BCisgender^ refers to an individual whose sex assigned at birth is the a parent of an adolescent who identified as lesbian, gay, bi- same as their current gender identity. Under parent sexual orientation, sexual, transgender, queer, or any other nonheterosexual or BOther^ included one parent who identified as pansexual and one who noncisgender identity; (2) have an LGBTQ adolescent aged identified as heterosexual with same-sex attractions 114 Sex Res Soc Policy (2018) 15:111–122 members of the research team, consisted of at least nine par- for us to cover in these programs?^ and BWhat format do you ticipants, and took place over two consecutive days. Questions think would be best for these programs? (e.g., just you and were posted each morning, and participants were permitted to your child, a group of children and parents, an online form)?^ answer at their convenience (participants were asked to log onto the forum two to three times per day). Moderators Coding and Analysis prompted participants who did not respond and probed re- spondents for clarification or additional information. Each participant’s transcript was imported into Dedoose Participants were able to see and comment on one another’s mixed-methods software for analysis. Analysis focused on posts. This online forum methodology is particularly helpful individual-level transcripts rather than group narratives for engaging marginalized groups (e.g., parents of LGBTQ (Carey & Smith, 1994), which enabled us to quantify the teens), because it allows some anonymity among participants presence of codes in individual responses and to make com- while also encouraging interaction in order to generate more parisons across individuals in frequency of code application. detailed responses. Participants who responded to at least Given the online nature of the focus groups, many indicators 1 day of the focus groups received a $30 Visa gift card. All of group consensus could not be coded feasibly (e.g., nod- procedures were approved by the Institutional Review Board ding), so individual-level transcripts were preferable. Of note, at Northwestern University. Of note, we conducted a parallel individual-level transcripts also allowed the coder to see par- set of online focus groups with cisgender sexual minority boys ticipants’ responses to other participant comments, which pro- that asked analogous questions, and those data are reported vided a sense of group discussion and consensus. Codes were elsewhere (Feinstein et al., 2017). generated based on the first several transcripts, reexamined, and refined using the constant comparison method (Taylor & Measures Bogdan, 1998). In this method, the analysis was a dynamic process, with each transcript informing the analysis of further Demographics Participants reported their own age, sexual ori- transcripts. A codebook was created with codes, brief descrip- entation, and race/ethnicity. They also reported on the age, tions, and when necessary for clarity included illustrative quo- sexual orientation, and gender identity of their child. tations (MacQueen, McLellan, Kay, & Milstein, 1998). We coded both deductively and inductively to examine patterns Focus Group Guide of interest while also allowing themes to emerge throughout the analysis. Thus, we began with a preliminary codebook, but Focus group questions were organized into three themes: (1) expanded it as unexpected themes came up. Codes were ap- parent-adolescent relationships, (2) parent-adolescent com- plied to each transcript to identify excerpts broadly munication about sex and dating, and (3) parental knowledge representing each key topic covered during the focus group, and monitoring of dating and sex behaviors. First, we asked with subcodes developing as examples of themes emerged several questions in order to characterize parents’ relation- from the transcripts. Two team members coded the transcripts, ships with their LGBTQ teens such as BHow would you de- and reliability was tested on 25% of the transcripts. The coders scribe the quality of your relationship with your [LGBTQ] achieved a kappa score of.76, indicating good agreement teen?^ and BIn what ways has your teen’s sexual orientation (McHugh, 2012). Participant quotes are presented verbatim or gender identity affected your relationship with them?^ For with the exception of minor edits to spelling and grammar to parent-adolescent communication about sex and dating, they facilitate readability. Note that all percentages below refer to were asked questions such as BIn what ways have you talked the percent of parents who endorsed a given code among those about or helped your teen think about sex and/or staying who provided relevant data for each theme. healthy while having sex?^ and BWhat additional challenges do you face discussing sex with your child because they are LGBTQ?^ For parental knowledge and monitoring, they were Results asked questions such as BHow do you keep track of whether your teen is dating and what they do with people they are Parent-Adolescent Relationships dating?,^ BWhat rules or limits, if any, do you set with your teen related to sexual activity?,^ and BWhat additional chal- See Table 2 for a summary of qualitative codes and frequency lenges do you face monitoring your child because they are of code application, split by adolescent gender identity (i.e., LGBTQ?^ Finally, a subset of parents (i.e., the second and cisgender male, cisgender female, TGNC). Most parents third focus groups; n = 24) were asked about their opinions (86%) described the quality of their relationship with their related to developing family-based programs to improve the adolescent as good or great, and 20 parents (48%) said that health and well-being of LGBTQ teens. These parents were their teen’s disclosure of their sexual orientation or gender asked: BWhat health-related topics would be most important identity improved their relationship with their child. For Sex Res Soc Policy (2018) 15:111–122 115 Table 2 Counts and percentages of codes and subcodes, split by teen gender identity Code Subcode Child gender identity All Cisgender Cisgender Transgender/ male female gender nonconforming Count % Count Count Count Parent-adolescent relationships Quality of parent-adolescent Good/great 32 86% 11 9 12 relationships (n = 37) Not good 1 3% 1 0 0 Good with participant, but not their partner 4 11% 1 0 3 Effect of sexual orientation or gender Improved relationship 20 48% 6 3 11 identity on relationships (n = 42) Negatively impacted relationship 4 10% 0 3 1 Did not affect relationship 13 31% 4 5 4 Different effect on relationship 5 12% 1 0 4 with one parent versus another Other challenges related to Relieved when teen came out 16 36% 10 3 3 coming out (n = 44) Grieved loss of heterosexual/cisgender child 13 30% 3 3 7 Strained relationship between parents 5 11% 3 0 2 Became more worried about teen 26 59% 11 4 11 Challenges related to teen’s mental health 19 43% 6 4 9 Challenges related to religion 15 34% 2 4 9 Communication of dating and sexual health Sexual health topics discussed with teens Protection for sex 24 77% 9 6 9 (n = 31) Health risks associated with sex 15 48% 6 4 5 Get to know someone before sex 11 35% 6 1 4 Sexual consent 6 19% 3 0 3 Do not discuss sex 3 10% 0 1 2 Challenges related to Discomfort talking about sex 11 31% 5 2 4 discussing sex (n = 35) Lack of knowledge about LGBTQ sexuality 11 31% 4 4 3 Parental knowledge and monitoring Parental knowledge of adolescent Reported tracking teen dating behavior 28 88% 9 9 10 activities (n = 32) Tracking by knowing teens’ friends and 23 72% 7 7 9 whereabouts Tracking by talking and asking questions 13 41% 5 3 5 Tracking social media 6 19% 3 3 0 Consequences for risky sexual Lecture teen about safer sex 13 81% 3 3 7 behavior (n = 16) Express disappointment 7 44% 3 1 3 Punish teen 2 13% 0 0 2 Effect of sexual orientation or Had an influence on parenting practices 13 52% 3 5 5 gender identity on parental related to sex and dating monitoring (n = 35) Same-sex sleepovers 10 29% 3 3 4 Mobile apps to meet partners 11 31% 3 2 6 Predators 8 23% 4 1 3 Gender minority teens being outed 3 9% 0 0 3 Preferences for family-based LGBTQ teen health programs Content (n = 22) Mental health issues 15 68% 3 4 8 Sexual health 16 73% 2 7 7 Sexuality and gender 5 23% 0 3 2 Format (n = 21) Parents/teens together in a group 6 29% 2 2 2 Parents/teens separate 9 43% 0 3 6 Expressed discomfort talking about sex in a 5 24% 1 1 3 parent/teen group Online 11 52% 2 4 5 Church-based 1 5% 1 0 0 The sample included 44 parents, but percentages are based on how many parents provided data relevant to each code (noted in the code column); for the code Bparent-adolescent relationships,^ counts for the subcodes Bquality of parent-adolescent relationships^ and Beffect of teen sexual orientation or gender identity on relationships^ are mutually exclusive (i.e., each parent was only counted toward one subcode); for all other codes, counts for the subcodes are not mutually exclusive instance, a mother of a 16-year-old cisgender gay boy said: BI he told me, we became closer. We kind of clung together to try think the way that it has changed our relationship is that after to figure this out and keep him safe.^ Another third (31%) said 116 Sex Res Soc Policy (2018) 15:111–122 that their teen’s sexual orientation or gender identity did not While not specifically related to parent-adolescent relation- affect the quality of their relationship with their child. Four ships, parents spontaneously discussed several other issues parents (11%) stated that they themselves had a good relation- they found relevant to their relationship with their teen and ship with their adolescent but that their partner did not, and the coming out process, including mental health problems and parents of TGNC teens endorsed this code more frequently religious issues. Nearly half of parents (43%) described the than did parents of cisgender boys and girls. Similarly, five challenges of parenting adolescents who struggled with men- parents (12%) said that their teen’s initial coming out had a tal health problems (e.g., depression, anxiety) and the effects more negative effect on their partner, and parents of cisgender of mental health on their relationship with their teen. One third girls endorsed this code more frequently. As one parent said: (34%) also described challenges related to religion, such as reconciling religious views with love for one’s child, dealing I often feel in the middle of [my husband and teen] and with negative attitudes within one’s religious community, and my husband says I side with [my teen] all the time and helping teens stay religiously involved after coming out. override him. The truth is I probably do which puts a Parents of cisgender girls and TGNC teens discussed religious strain on our relationship…It’s obvious with their inter- issues more frequently than did parents of cisgender boys. actions that my husband resents [my teen]. - Parent of 17-year-old, gay, transgender boy Communication About Dating and Sexual Health Most parents stated that they were willing to talk to their teens Finally, four parents (10%) stated that their teen’s sexual about sex and dating, and they described various parenting orientation or gender identity initially had a negative impact strategies for doing so. The largest group of parents (77%) on their relationship with their teen, but these parents all said described talking to their teens about using protection for that their relationships with their teens had improved again sex (e.g., condoms), and about half (48%) described educating with time. Only one parent (3%) described a relationship with their teens about the health risks associated with sex. their teen that was not good. Although less commonly noted, some parents mentioned Some parents discussed their feelings about their teen’s sexual talking to their teens about the importance of getting to know orientation or gender identity in more nuanced ways. For exam- someone before having sex (35%) and the importance of sex ple, a number of parents (36%) described feeling relieved when being consensual (19%). For parents of TGNC teens in par- their teen came out because they had suspected that their teen ticular, conversations about getting to know partners before was LGBTQ, and parents of cisgender boys endorsed this code sex and sexual consent focused on worries about their teens most frequently. In contrast, nearly one third (30%) described being harmed if they had not disclosed to their partners that grieving the loss of their presumably heterosexual and/or they were TGNC: BI wanted my daughter to know that if you cisgender child, and parents of cisgender girls and TGNC teens do not tell your partner you are transgender from the begin- endorsed this code more frequently than did parents of cisgender ning, they may kill you^ (mother of a 17-year-old heterosex- boys. A mother of a transgender boy said: ual transgender girl). Parents of cisgender boys also more frequently discussed the importance of getting to know some- I felt devastated…I was petrified for his future, for being one before sex, and parents of cisgender boys and TGNC ostracized possibly, disliked, hated or worse hurt by teens were more likely to discuss issues related to sexual con- someone who doesn't understand…I think it was partly sent. Of note, the majority of parents noted that the sexual my expectations held for the future and partly because it orientation or gender identity of their teen did not affect their made me extremely sad that this could have happened to ability to communicate with their children about dating and him, born with the wrong body parts. We said some sex, nor did it affect the content of those conversations. As one pretty stupid, naive things to him back then. mother of a 17-year-old cisgender gay boy stated: B[We had - Parent of a 17-year-old, gay, transgender boy the] same advice for both our [gay and straight] sons…use condoms, no means no, and be careful about who you share Over half of parents (59%) described becoming more wor- your body with.^ ried about their teen after they came out as LGBTQ, and this Parents noted several challenges related to communicating theme was particularly prominent among parents of cisgender with their teens about sexual health, including discomfort with boys and TGNC teens. In summarizing other parents’ com- talking about sex (on the part of the parent, child, or both) and ments in the forum, a mother of a 17-year-old cisgender gay not being knowledgeable about sex for LGBTQ persons. boy stated: BThat seems to be a common theme with us: fear About one third (31%) stated that talking to their teen about of what’s going to happen to them out there. In our house he’s sex was uncomfortable for them, and this was consistent re- safe, no question. But I have no idea what’s going on out gardless of teen gender identity. A mother of a 17-year-old there.^ same-sex attracted transgender boy said: BWe really don’t talk Sex Res Soc Policy (2018) 15:111–122 117 about sex. It is a subject that makes me and my son really Half of the parents (52%) specifically stated that their teen’s uncomfortable…I know that I am avoiding my responsibili- sexual orientation or gender identity had an influence on their ties, but I prefer to let him have conversations about sex in ability to set rules and limits related to sex and dating. Many [different] settings.^ Beyond discomfort, about a third of par- parents discussed certain contexts or situations about which they ents (31%) described feeling unequipped to talk to their teen worried or did not know how to approach because of their child’s about sex for LGBTQ persons, and parents of cisgender girls sexual orientation or gender identity. First, nearly a third (29%) were somewhat more likely to endorse this theme. A mother described struggling with how to handle their teens wanting to of a 17-year-old cisgender gay boy said: BMy challenge have sleepovers. One mother said: around talking about sex is that I have no idea about what sex is really like for men, especially for gay men.^ Several One thing that has had me wondering is how other par- parents solved this issue by having their teen talk to an ents of [LGBTQ] teens deal with same-sex overnights. LGBTQ-identified friend about sex. One mother said: At [my child’s] age we would never allow [her to] spend the night with the opposite sex if she were straight. When [my daughter] came out, I had no idea what prac- - Parent of a 14-year-old, lesbian, cisgender girl tical information to give her, since I'm straight, so I sent her to a friend of mine who is a lesbian for the ‘gay sex’ Most often, discussion of sleepovers reflected confusion about talk…. I felt challenged that I’m straight, my daughter is how to consistently enforce rules across their LGBTQ and het- dating a gal, and I didn’t know anything about that. All erosexual children. A third (31%) also expressed concerns about my sex talks were about how not to get pregnant and their teens using mobile apps to meet partners. One parent noted: how babies are conceived and all that. - Parent of a 16-year-old, bisexual, cisgender girl [My son has] used [an app] and found a lovely boyfriend…[and] he returned to the apps for hookups. These are not dates. These are following someone to their apartment for sex. It’s dangerous because they’re Parental Knowledge and Monitoring not in a public place…So the apps, they are not evil. They can be used in risky ways. Most parents (88%) said that they actively tracked their teen’s - Parent of a 16-year-old, bisexual, cisgender boy dating behavior, and in general, parents of cisgender girls re- ported doing so more frequently than did parents of cisgender Similarly, about a quarter (23%) expressed concerns about boys and TGNC teens. Several strategies were described, in- predators, and this was more frequently endorsed by parents cluding knowing teens’ friends and whereabouts (72%), of cisgender boys and TGNC teens. One parent stated: talking to their teens and asking questions about their dating lives and other activities (41%), and tracking their social me- The challenge I mostly feel is protecting them from dia (19%). We observed no pronounced differences in specific predators. They are in a very vulnerable place, and parental monitoring strategies by teen gender identity. Further, sometimes I feel they are desperate for a true friend- many parents continued to re-iterate that their teen’s sexual ship/relationship. If they were to let someone in, I would orientation or gender identity did not affect the strategies they really want to get to know the person and understand used to monitor their teens. their intentions. Parents were also asked about consequences they would - Parent of a 16-year-old, questioning, gender impose on their teen for various sex risk behaviors. Most nonconforming teen (81%) said they would talk to or lecture their teen about safer sex (including condom use and getting tested for HIV/STIs) if Finally, a handful of parents (9%) expressed concern about they found out their teen was having sex without protection. their TGNC teens being outed. Noting this fear, one parent of a About half (44%) said they would be upset and would express 15-year-old queer transgender boy said: BMy only fear with my disappointment with their child, and a minority (13%) said child’s sex life in the future is that once they start to pass, they they would punish their teen but did not specify the punish- could face violence if someone finds out they are transgender ment. Interestingly, many parents reported that they had diffi- during sex.^ culty answering these questions. They often stated that their children were not currently dating or having sex, so they had Preferences for Family-Based LGBTQ Teen Health not needed to establish or enforce rules or consequences yet: Programs BAt this time I do not feel as if I have to set rules and bound- aries. They have a few close friends and they are not involved A majority of parents stated that family-based programs sexually^ (mother of a 16-year-old bisexual transgender boy). should focus on sexual health (73%) and mental health issues 118 Sex Res Soc Policy (2018) 15:111–122 (68%). About a quarter of parents (23%) also expressed an - Parent of a 17-year-old, gay, cisgender boy interest in focusing on sexuality and gender more broadly to facilitate mutual understanding. With regard to the specific In general, parents who were enthusiastic about online pro- format of family-based programming, 43% said that parents grams suggested that online approaches may help remove and teens should be separated into different groups because barriers (e.g., discomfort, logistics) to implementing family- the needs of parents and teens are different and because they based programs in groups. Of note, while there was some felt it might alleviate discomfort and awkwardness. However, disagreement about program format, parents were enthusiastic most of these parents also noted the benefits of a group format about family-based programming, and no parents described if split into parent and teen groups: negative opinions about such programs. I would appreciate a group setting. I don’t have an op- portunity to talk with other parents whose kids are Discussion LGBTQ. Perhaps a topic brought up by a group member will help us think differently or get a heads up of a The purpose of this study was to understand more about the potential issue. Having other kids talk [in groups] might specific practices used by parents to prevent negative sexual also help my kid talk through something. health outcomes in their LGBTQ teens in order to inform the - Parent of a 17-year-old, gay, cisgender boy development of family-based sexual health programs. Parents overwhelmingly described positive relationships with their Due to the lower number of parents who responded to these LGBTQ adolescents, but many also noted that they went questions, we were not able to assess gender identity differ- through a transition process in which they struggled to come ences in theme endorsement. to terms with their child’s identity. Although most parents Similarly, a quarter (24%) said that it would be uncomfortable stated that their child’s LGBTQ identity did not affect their to talk about sex in a group of several parent-adolescent dyads, ability to effectively parent, these same parents also discussed suggesting that discomfort may be a barrier to implementing many struggles related to parenting their LGBTQ children family-based interventions in group settings. In contrast, about about healthy sexuality, including lack of understanding about a third (29%) said that parents and teens should participate to- LGBTQ-specific sexuality, discomfort communicating about gether in a group of other parents and teens in order to learn from sex with their children, and heightened fear about their chil- others and build community. In support of joint parent-adolescent dren having negative experiences with sexuality. Overall, programming, a mother of a 15-year-old queer transgender boy these findings suggest that many parents of LGBTQ adoles- pointed out that parents and teens often learn from one another: cents are invested in helping their children have positive sex- BWe run a camp for LGBTQ youth, and usually it’s the teens ual health outcomes but that they require education and sup- teaching the adult volunteers rather than the other way around.^ port in order to do so. One mother summarized these themes: While the vast majority of parents (86%) described having supportive relationships with their LGBTQ teens, it was ap- We virtually have no support groups [for LGBTQ teens] parent that many of these relationships had not always been in the area we live and it is much needed. I think a entirely supportive. Many parents talked about going through format where maybe there is a parent group and a child a transition period after their child came out as LGBTQ, which group that meet at the same time but separately...and included a period of grief in which parents mourned the loss of occasionally together [would be best]. It would be great the future they envisioned for their child. Some parents noted if it included overall well-being; not only drug and sex- that they may have communicated their grief and worries to ual health, but also mental health, support for coming their children, which could have led their teens to believe they out and everyday challenges. held negative attitudes about their LGBTQ identity. This - Parent of a 15-year-old, lesbian, cisgender girl transition period is strikingly similar to that reported by Saltzburg (2004) more than a decade ago, indicating that even When asked about online programs, about half of the par- in the context of societal change in attitudes toward LGBTQ ents (52%) were enthusiastic about using an online format for individuals, parents today still need support coping after their family-based programs. One mother stated: child comes out. Given that coming out is often emotionally tumultuous for the teen as well, this is a particularly vulnerable Online [would be best] for my son. He may feel more period in which both parents and adolescents need support in comfortable talking that way with others. [It] would be order to optimize the well-being of the child. Further, many great to also have a leader to lead conversations and parents noted that their teens did not have positive and sup- guide them. I don’t think that my son would be comfort- portive relationships with their other parent, which indicates able in a group discussion in person. that LGBTQ teens may still experience the negative Sex Res Soc Policy (2018) 15:111–122 119 repercussions of having a rejecting parent. This speaks to the on to say that she felt challenged providing advice to her gay importance of optimizing the supportive relationships these son about sexual health because she had no idea what sex was teens do have in order to buffer LGBTQ teens against the like for gay men. Various approaches could be used to provide consequences of stigma and rejection. this information to parents of LGBTQ adolescents, such as With regard to specific parenting practices, the vast major- comprehensive online resources or formal parenting ity of parents said that they were willing to and had discussed programs. sexual health with their teens, but many discussed specific Parents also described various techniques for keeping track challenges with regard to communicating about sex. First, of their child’s dating and sexual activity and enforcing rules consistent with previous research with heterosexual and consequences. These strategies mirrored those commonly (Malacane & Breckmeyer, 2016) and LGBTQ adolescents used by parents of heterosexual youth, including methods for (Macapagal et al., 2016), parents noted that it was very un- increasing knowledge of teen’s activities (e.g., getting to know comfortable for them and/or their children to talk about sex teen’s friends and romantic interests, tracking teen’s social with one another, and this was consistent across parents of media) and enforcement of consequences for breaking rules teens with all gender identities. Further, a third also stated that about dating and sex (e.g., punishment, expressing disappoint- they felt unequipped to provide concrete and accurate advice ment). Interestingly, many parents noted that they did not need about LGBTQ sexuality, and this was more frequently en- to monitor their teens because they believed their teens were dorsed by parents of cisgender girls. Importantly, avoidance not dating or having sex. This contradicts our focus groups of communication about sex has been linked to increased sex- with teens in which cisgender sexual minority boys stated they ual risk behaviors and a lower likelihood of HIV testing often misled their parents about who they were dating or omit- among gay and bisexual boys and other YMSM (Bouris ted specific details about their activities due to concerns about et al., 2015; LaSala et al., 2016), and it is plausible that such being treated differently because of their sexual orientation avoidance would impact sexual health outcomes among (Feinstein et al., 2017). Given that parental knowledge is a cisgender girls and TGNC teens as well. Resources are clearly robust predictor of better sexual health outcomes (Dittus needed to help all parents, regardless of their child’s sexual et al., 2015; Mustanski et al., 2017), interventions that focus orientation or gender identity, overcome the awkwardness and on building emotionally supportive relationships between par- discomfort that can result from conversations about sexual ents and LGBTQ adolescents that are characterized by open health. However, parents of LGBTQ adolescents need addi- and honest communication may help parents have a better tional information and support specific to LGBTQ sexuality, understanding of their teen’s activities so as to help them nav- and our data indicate this may be especially true for parents of igate sexuality and dating more effectively and enforce rules cisgender girls. as needed. Even among those parents who actively discuss sex and When looking across parent perspectives on sexual health dating with their children, parents may intentionally or unin- communication and parental monitoring with LGBTQ adoles- tentionally omit LGBTQ-specific sexual health information cents, many parents shared concerns about sexual health that from these conversations (or even provide inaccurate informa- were specific to LGBTQ teens. For example, parents often tion). Consistent with prior research (Thoma & Huebner, expressed concerns about their teen’s risk of being exposed 2014), omitted or inaccurate information could place to Bpredators^ or being victimized, and this was more fre- LGBTQ teens at risk for various negative health outcomes, quently endorsed by parents of cisgender boys and TGNC including HIV, STIs, unintended pregnancy, or unhealthy ro- teens. Being victimized by Bpredators^ is not necessarily mantic relationships, even when parents attempt to communi- unique to, or more common among, LGBTQ youth, but par- cate openly with their teens. In the current study, most parents ents noted that their child’s coming out heightened this con- stated that their child’s LGBTQ identity had no effect on the cern. For parents of cisgender boys, they were less concerned content of their sexual health conversations and that they gave about victimization when they perceived their child to be het- the same advice to their heterosexual and LGBTQ children. erosexual, possibly because of a general societal belief that While it is encouraging that these parents are talking with their heterosexual boys are less susceptible to victimization than LGBTQ teens about sex, this approach omits information that are girls. For parents of TGNC teens, their heightened worry is critical to sexual health and prevention (e.g., sexual safety is not surprising given the many high-profile examples of specific to anal sex). Furthermore, this finding starkly con- violence toward transgender people in the media. Many par- trasts with the parallel focus groups we conducted with teens, ents also worried about the use of mobile apps and other in which many cisgender sexual minority boys stated that their online media to meet friends and romantic partners and the parents had more open conversations about sex and dating potential for victimization to occur through these media. with their heterosexual siblings (Feinstein et al., 2017). While the use of online media does not inherently lead to Reinforcing this point, one mother who initially said she gave victimization, it may be more difficult for parents to monitor the same advice to their heterosexual and gay sons later went their child’s dating behavior when conducted online. 120 Sex Res Soc Policy (2018) 15:111–122 Experimentation with dating is a normative developmental specific sexual health information, many parents and teens milestone for adolescents which allows them to build healthy would benefit from skills for building warmth and emotional relationship skills (Collins, 2003), and meeting other teens support with one another, such as gaining mutual understand- online may be necessary for LGBTQ teens due to a lack of ing of parent and teen perspectives and increasing connected- available partners in more traditional settings (e.g., at school; ness through shared interests. Building supportive relation- Macapagal, Greene, Rivera, & Mustanski, 2015). These data ships can also serve as a platform on which effective commu- suggest that parents need more information about dating con- nication skills can be learned in order to help parents to better texts that are specific to LGBTQ individuals, as well as guid- understand the thoughts and feelings of their LGBTQ teens ance about how to help their teens avoid any risks associated related to their sexuality, as well as to help parents impart with these contexts. useful advice and enforce limitations. It is also important to Another pattern that emerged across topics was that most acknowledge that parents spontaneously identified several parents believed their child’s LGBTQ identity did not have an other issues they struggled to address with their teens beyond effect on their parenting practices related to sexual health. sexual health, including mental health and religious issues. However, these same parents also often noted barriers to effective This indicates that parents and teens may also benefit from parenting specific to LGBTQ individuals (e.g., lack of knowl- programs that focus on overall health and well-being, as op- edge about LGBTQ sexuality), which undermined their prior posed to sexuality-specific interventions. statements. Furthermore, many cisgender sexual minority boys Parents in these focus groups did not come to a clear consen- in our parallel focus groups with teens described the opposite; sus about the preferred format of these types of programs, though coming out to parents often had a negative impact on the manner many parents felt that their teens would be reluctant to participate in which their parents talked to them about sex and dating in programs that convened groups of parent-adolescent dyads in (Feinstein et al., 2017). Given that many of these teens also stated person. Some parents offered suggestions for overcoming this that they concealed their dating behaviors from their parents reluctance. Several stated that programs might benefit from sep- either because they were not out or they feared negative reac- arating parents and teens into different groups and later bringing tions, there is a clear need for improved communication between everyone together for mutual discussion. When asked about on- parents and teens about LGBTQ sexuality and dating. line forums for parent-adolescent programs, many noted that the With these data in mind, there is a clear need for family- online forum might help reduce barriers to attending in person based programs that aim to improve the health and well-being while also helping build community. It is important to note that of LGBTQ teens. There is a robust literature on parent-based not all parents will be prepared to attend such programs. Parent- HIV prevention and sexual health programs for heterosexual only programs, particularly those administered online, may be adolescents, and common elements of effective interventions more effective at reaching parents who are somewhat less are parent-child communication skills training, sex education accepting but are interested in seeking information. For example, for parents, promotion of increased family involvement, and the recently developed BLead with Love^ program is an innova- developmental and cultural tailoring (Santa Maria, Markham, tive brief video-based program for parents who have recently Bluethmann, & Mullen, 2015; Sutton, Lasswell, Lanier, & learned that their child is LGBTQ that aims to reduce rejecting Miller, 2014). Little to nothing is known about whether these behaviors and improve family interaction (Huebner, Rullo, programs are efficacious for LGBTQ adolescents, despite the Thoma, McGarrity, & Mackenzie, 2013). Finally, it is important fact that many LGBTQ youth are likely enrolled in programs to acknowledge that the least accepting parents of LGBTQ teens intended for heterosexual youth (Ocasio, Feaster, & Prado, are unlikely to participate in any of these formats, and in these 2016). Further, most parents in the current study indicated that cases, developing programs for teens who are not out or who their primary barriers to promoting teenage sexual health were have experienced parental rejection that help them to navigate related to LGBTQ-specific issues that likely would not be these complex relationships with their parents is critically impor- addressed in broader sexual health programs, including infor- tant. In sum, family-based sexual health programs for LGBTQ mation about LGBTQ sexuality, navigating dating environ- youth have tremendous potential, but multiple intervention mo- ments that are unique to LGBTQ young people (e.g., certain dalities that are able to engage parents at varying levels of accep- online environments or mobile apps), and maintaining consis- tance and knowledge will likely be needed to address the needs tent rule enforcement across heterosexual and LGBTQ teens of all parents and their LGBTQ teens. (e.g., same-sex sleepovers). These findings should be interpreted in the context of sev- Family-based programs for LGBTQ adolescents should eral important limitations. First, this sample likely reflects par- therefore focus on providing substantial psychoeducation ents who are generally more accepting of their teens’ LGBTQ about LGBTQ sexuality, dating, and identity development to identity than the average parent simply by nature of the fact parents. Teens should also be provided with tailored sexual that they were willing to participate in a focus group about health information, because it is clear that not all parents are their LGBTQ teens. While this likely influenced our findings, capable of providing this education to their children. Beyond we also note that many of the parents described struggles they Sex Res Soc Policy (2018) 15:111–122 121 previously had in coming to terms with their child’s identity, Bouris, A., Hill, B. J., Fisher, K., Erickson, G., & Schneider, J. A. (2015). Mother-son communication about sex and routine human immuno- which allows for some understanding of the experiences of deficiency virus testing among younger men of color who have sex less accepting parents. Furthermore, this sample is largely with men. Journal of Adolescent Health, 57, 515–522. https://doi. composed of White female parents, and future research should org/10.1016/j.jadohealth.2015.07.007. seek to understand the perspectives of fathers and racial/ethnic Carey, M. A., & Smith, M. W. (1994). Capturing the group effect in focus minority parents, as research has documented some differ- groups: A special concern in analysis. Qual Health Res, 4, 123–127. https://doi.org/10.1177/104973239400400108. ences in parenting style by race and gender (Cox, 2006; CDC. (2016). HIV Surveillance Report, 2015. Retrieved from http:// Pagano, Hirsch, Deutsch, & McAdams, 2003). Our qualitative www.cdc.gov/hiv/library/reports/surveillance/. method involved asynchronous online focus groups, which Clark, H., Babu, A. S., Wiewel, E. W., Opoku, J., & Crepaz, N. (2016). allowed for participant anonymity and greater accessibility Diagnosed HIV infection in transgender adults and adolescents: Results from the national HIV surveillance system, 2009-2014. for parents across the USA. However, while participants were AIDS and Behavior, 21, 2774–2783. https://doi.org/10.1007/ able to respond to one another’s comments, the data collected s10461-016-1656-7. via real-time in-person focus groups may differ and allow for Collins, W. A. (2003). More than myth: The developmental significance better observation of certain types of data (e.g., group consen- of romantic relationships during adolescence. Journal of Research sus). Also, these data are qualitative in nature, so further ex- on Adolescence, 13, 1–24. https://doi.org/10.1111/1532-7795. 1301001. amination of the impact of parenting on sexual health out- Cox, M. F. (2006). Racial differences in parenting dimensions and ado- comes among LGBTQ teens using quantitative longitudinal lescent condom use at sexual debut. Public Health Nursing, 23, 2– methods is necessary in order to more firmly establish causal- 10. https://doi.org/10.1111/j.0737-1209.2006.230102.x. ity. Finally, while the current analyses focused on parenting Dishion, T. J., & McMahon, R. J. (1998). Parental monitoring and the prevention of child and adolescent problem behavior: A conceptual related to sexual health, parents also discussed the need for and empirical formulation. Clinical Child and Family Psychology programming that addresses other aspects of teen health, most Review, 1, 61–75. notably mental health. Future work should focus on better Dittus, P. J., Michael, S. L., Becasen, J. S., Gloppen, K. M., McCarthy, K., understanding parenting needs regarding other health needs & Guilamo-Ramos, V. (2015). Parental monitoring and its associa- tions with adolescent sexual risk behavior: A meta-analysis. of LGBTQ adolescents. Pediatrics, 136, e1587–e1599. https://doi.org/10.1542/peds.2015- Nevertheless, there is very little existing data on the relation- 0305. ships that parents have with their LGBTQ teens and the specific DuBois, L. Z., Macapagal, K. R., Rivera, Z., Prescott, T. L., Ybarra, M. practices used by parents of LGBTQ teens to promote sexual L., & Mustanski, B. (2015). To have sex or not to have sex? An health, particularly from the perspective of parents. These analy- online focus group study of sexual decision making among sexually experienced and inexperienced gay and bisexual adolescent men. ses are an important step toward understanding the barriers to and Archives of Sexual Behavior, 44, 2027–2040. https://doi.org/10. facilitators of optimizing parent-adolescent relationships in order 1007/s10508-015-0521-5. to prevent negative sexual health outcomes in these youth. The Feinstein, B. A., Thomann, M., Coventry, R., Macapagal, K., Mustanski, parents of the LGBTQ teens in our sample expressed attitudes B., & Newcomb, M. E. (2017). Gay and bisexual adolescent boys' perspectives on parent-adolescent relationships and parenting prac- and behaviors that indicated that their relationships with their tices related to teen sex and dating. Archives of Sexual Behavior. teens were generally supportive, but parents also identified many https://doi.org/10.1007/s10508-017-1057-7. barriers to promoting their teen’s sexual health. Based on these Garofalo, R., Mustanski, B., & Donenberg, G. (2008). Parents know and data, there is a clear need to provide parents of LGBTQ adoles- parents matter; is it time to develop family-based HIV prevention cents with the information and skills necessary to optimize their programs for young men who have sex with men? Journal of Adolescent Health, 43, 201–204. https://doi.org/10.1016/j. teen’s sexual health, and family-based programs for parents of jadohealth.2008.01.017. LGBTQ teens are long overdue for addressing these issues. Glick, S. N., & Golden, M. R. (2014). Early male partnership patterns, social support, and sexual risk behavior among young men who Acknowledgements This study was supported by grants from the Third have sex with men. AIDS and Behavior, 18, 1466–1475. https:// Coast Center for AIDS Research (PI: Newcomb) and the National doi.org/10.1007/s10461-013-0678-7. Institute on Minority Health and Health Disparities (R01MD009561; Grafsky, E. L. (2017). Deciding to come out to parents: Toward a model PIs: Fisher and Mustanski). of sexual orientation disclosure decisions. Family Process. https:// doi.org/10.1111/famp.12313. Hatzenbuehler, M. L. (2009). How does sexual minority stigma Bget under the skin^? A psychological mediation framework. Psychological Bulletin, 135, 707–730. https://doi.org/10.1111/j. References 1467-9280.2009.02441.x. Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective Bouris, A., Guilamo-Ramos, V., Jaccard, J., McCoy, W., Aranda, D., factors for alcohol and other drug problems in adolescence and early Pickard, A., & Boyer, C. B. (2010). The feasibility of a clinic- adulthood: Implications for substance abuse prevention. based parent intervention to prevent HIV, sexually transmitted infec- Psychological Bulletin, 112, 64–105. tions, and unintended pregnancies among Latino and African Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for American adolescents. AIDS Patient Care and STDS, 24, 381– clinical work with transgender and gender nonconforming clients: 387. https://doi.org/10.1089/apc.2009.0308. An adaptation of the minority stress model. Professional 122 Sex Res Soc Policy (2018) 15:111–122 Psychology-Research and Practice, 43, 460–467. https://doi.org/10. Journal of Adolescent Health, 59, 599–601. https://doi.org/10. 1037/A0029597. 1016/j.jadohealth.2016.07.008. Huebner, D. M., Rullo, J. E., Thoma, B. C., McGarrity, L. A., & Pagano, M. E., Hirsch, B. J., Deutsch, N. L., & McAdams, D. P. (2003). The Mackenzie, J. (2013). Piloting lead with love: A film-based inter- transmission of values to school-age and young adult offspring: Race vention to improve parents' responses to their lesbian, gay, and bi- and gender differences in parenting. Journal of Feminist Family sexual children. Journal of Primary Prevention, 34, 359–369. Therapy, 14, 13–36. https://doi.org/10.1300/J086v14n03_02. https://doi.org/10.1007/s10935-013-0319-y. Poteat, T., Scheim, A., Xavier, J., Reisner, S., & Baral, S. (2016). Global Kann, L., Olsen, E. O., McManus, T., Harris, W. A., Shanklin, S. L., Flint, epidemiology of HIV infection and related syndemics affecting K. H., … Zaza, S. (2016). Sexual identity, sex of sexual contacts, transgender people. Journal of Acquired Immune Deficiency and health-related behaviors among students in grades 9-12— Syndromes, 72(Suppl 3), S210–S219. https://doi.org/10.1097/QAI. United States and selected sites, 2015. Morbidity and Mortality 0000000000001087. Weekly Report. Surveillance Summaries, 65, 1–202. https://doi.org/ Rose, I. D., & Friedman, D. B. (2016). HIV information needs of parents 10.15585/mmwr.ss6509a1. of young men who have sex with men. Health Information and Kincaid, C., Jones, D. J., Sterrett, E., & McKee, L. (2012). A review of Libraries Journal, 33, 308–322. https://doi.org/10.1111/hir.12152. parenting and adolescent sexual behavior: The moderating role of Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009). Family rejec- gender. Clinical Psychology Review, 32, 177–188. https://doi.org/ tion as a predictor of negative health outcomes in white and Latino 10.1016/j.cpr.2012.01.002. lesbian, gay, and bisexual young adults. Pediatrics, 123, 346–352. LaSala, M. C. (2007). Parental influence, gay youths, and safer sex. https://doi.org/10.1542/peds.2007-3524. Health and Social Work, 32, 49–55. Saewyc, E. M., Bearinger, L. H., Blum, R. W., & Resnick, M. D. (1999). LaSala, M. C. (2015). Condoms and connection: Parents, gay and bisex- Sexual intercourse, abuse and pregnancy among adolescent women: ual youth, and HIV risk. Journal of Marital and Family Therapy, 41, Does sexual orientation make a difference? Family Planning 451–464. https://doi.org/10.1111/jmft.12088. Perspectives, 31, 127–132. LaSala, M. C., Siebert, C. F., Fedor, J. P., & Revere, E. J. (2016). The role of family interactions in HIV risk for gay and bisexual male youth: A Saewyc, E. M., Poon, C. S., Homma, Y., & Skay, C. L. (2008). Stigma pilot study. Journal of Family Social Work, 19, 113–131. management? The links between enacted stigma and teen pregnancy Macapagal, K., Coventry, R., Arbeit, M. R., Fisher, C. B., & Mustanski, trends among gay, lesbian, and bisexual students in British B. (2016). BI won’t out myself just to do a survey^: Sexual and Columbia. Canadian Journal of Human Sexuality, 17, 123–139. gender minority adolescents’ perspectives on the risks and benefits Saltzburg, S. (2004). Learning that an adolescent child is gay or lesbian: of sex research. Archives of Sexual Behavior, 46, 1393–1409. https:// The parent experience. Soc Work, 49, 109–118. doi.org/10.1007/s10508-016-0784-5. Santa Maria, D., Markham, C., Bluethmann, S., & Mullen, P. D. (2015). Macapagal, K., Greene, G. J., Rivera, Z., & Mustanski, B. (2015). BThe Parent-based adolescent sexual health interventions and effect on best is always yet to come^: Relationship stages and processes communication outcomes: A systematic review and meta-analyses. among young LGBT couples. Journal of Family Psychology, 29, Perspectives on Sexual and Reproductive Health, 47, 37–50. https:// 309–320. https://doi.org/10.1037/fam0000094. doi.org/10.1363/47e2415. MacQueen, K. M., McLellan, E., Kay, K., & Milstein, B. (1998). Savin-Williams, R. C., & Ream, G. L. (2003). Sex variations in the Codebook development for team-based qualitative analysis. Field disclosure to parents of same-sex attractions. Journal of Family Methods, 10, 31. Psychology, 17, 429–438. Malacane, M., & Breckmeyer, J. J. (2016). A review of parent-based Stattin, H., & Kerr, M. (2000). Parental monitoring: A reinterpretation. barriers to parent-adolescent communication about sex and sexual- Child Development, 71, 1072–1085. ity: Implications for sex and family educators. American Journal of Sutton, M. Y., Lasswell, S. M., Lanier, Y., & Miller, K. S. (2014). Impact Sexuality Education, 11, 27–40. of parent-child communication interventions on sex behaviors and McHugh, M. L. (2012). Interrater reliability: The kappa statistic. cognitive outcomes for black/African-American and Hispanic/ Biochemia Medica, 22, 276–282. Latino youth: A systematic review, 1988-2012. Journal of Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, Adolescent Health, 54, 369–384. https://doi.org/10.1016/j. gay, and bisexual populations: Conceptual issues and research evi- jadohealth.2013.11.004. dence. Psychological Bulletin, 129, 674–697. https://doi.org/10. Taylor, S. J., & Bogdan, R. (1998). Introduction to qualitative research 1037/0033-2909.129.5.674. methods: A guidebook and resource (3rd ed.). New York: Wiley. Mustanski, B., Birkett, M., Greene, G. J., Hatzenbuehler, M. L., & Thoma, B. C., & Huebner, D. M. (2014). Parental monitoring, parent- Newcomb, M. E. (2014). Envisioning an America without sexual adolescent communication about sex, and sexual risk among young orientation inequities in adolescent health. American Journal of men who have sex with men. AIDS and Behavior, 18, 1604–1614. Public Health, 104, 218–225. https://doi.org/10.2105/AJPH.2013. https://doi.org/10.1007/s10461-014-0717-z. 301625. Widman, L., Choukas-Bradley, S., Noar, S. M., Nesi, J., & Garrett, K. Mustanski, B., Swann, G., Newcomb, M. E., & Prachand, N. (2017). (2016). Parent-adolescent sexual communication and adolescent Effects of parental monitoring and knowledge on substance use safer sex behavior: A meta-analysis. JAMA Pediatrics, 170, 52– and HIV risk behaviors among young men who have sex with 61. https://doi.org/10.1001/jamapediatrics.2015.2731. men: Results from three studies. AIDS and Behavior, 21, 2046– Wight, D., & Fullerton, D. (2013). A review of interventions with parents 2058. https://doi.org/10.1007/s10461-017-1761-2. to promote the sexual health of their children. Journal of Adolescent Ocasio, M. A., Feaster, D. J., & Prado, G. (2016). Substance use and Health, 52, 4–27. https://doi.org/10.1016/j.jadohealth.2012.04.014. sexual risk behavior in sexual minority hispanic adolescents. Reproduced with permission of copyright owner. Further reproduction prohibited without permission.