A PrActitioner’s resource Guide:

Helping Families 

to Support Their 

LGBT Children
AcKnoWLedGeMents

A Practitioner’s Resource Guide: Helping Families to Support Their LGBT Children was prepared by 

Caitlin Ryan, PhD, ACSW, Director of the Family Acceptance Project at San Francisco State University 

under contract number HHSP233201200519P for SAMHSA, HHS.

DISC

The views, opinions, and content of this publication are those of the author and do not necessarily reflect 

the views, opinions, or policies of SAMHSA or HHS.

PuBLic doMAin notice

All materials appearing in this publication are in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. The publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, 

SAMHSA.

E

This publication may be downloaded or ordered at http://store.samhsa.gov/. Or call SAMHSA at 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

RECO

Substance Abuse and Mental Health Services Administration, A Practitioner’s Resource Guide: Helping 

Families to Support Their LGBT Children. HHS Publication No. PEP14-LGBTKIDS. Rockville, MD: 

Substance Abuse and Mental Health Services Administration, 2014.
Table of Contents

I2

critical role of Families in reducing 

risk & Promoting Well-Being 4

Helping Families decrease risk & 

increase Well-Being for their LGBt children 8

increasing Family support: 

How to Help right now 11

resources for Practitioners and Families 12

endnotes 13 

references 14
2 A Practitioner’s resource Guide: Helping Families to support their LGBt children

Introduction

Since the early 1990s, young people have increasingly 

been coming out or identifying as lesbian, gay, and 

bisexual, and more recently as transgender, during adolescence. This coincides with greater awareness and 

visibility of lesbian, gay, bisexual, and transgender (LGBT) 

people in society, the media, schools, congregations, and 

communities. More widespread access to information about 

sexual orientation, gender identity, and LGBT resources 

through the internet has contributed to significant changes in 

how children and adolescents learn about LGBT people and 

their lives. And increasingly, this has helped young people 

come out at much earlier ages than prior generations of 

LGBT adults. (For information about sexual orientation and 

gender identity, see “Definitions” on the following page.)

Coming out at earlier ages has important implications for how 

practitioners work with children, youth, and families, how they 

educate parents, families, and caregivers about sexual orientation and gender identity, and how services are provided to 

LGBT children and adolescents. Historically, services for LGB 

youth and later for transgender youth were developed to protect them from harm, including from parents and families that 

were perceived as rejecting or incapable of supporting their 

sexual minority children. As a result, services evolved over 

several decades to serve LGBT adolescents either individually 

– like adults – or through peer support, and not in the context 

of their families (Ryan, 2004; Ryan & Chen-Hayes, 2013). 

Even though families, in general, play a critical role in 

child and adolescent development and well-being, and 

connections to family are protective against major health 

risks (Resnick et al., 1997), until recently little was known 

about how parents reacted to their LGBT children from the 

perspective of parents and caregivers (Bouris et al., 2010; 

Diamond et al., 2012; Ryan, 2010) or how they adapted and 

adjusted to their LGBT children over time. As a result, many 

practitioners assumed that little could be done to help parents and families who were perceived as rejecting to support 

their LGBT children. So few practitioners tried to engage or 

work with these families (Ryan & Chen-Hayes, 2013). Nevertheless, earlier ages of coming out coupled with emerging 

research which indicates that families of LGBT adolescents 

contribute significantly to their children’s health and wellbeing call for a paradigm shift in how services and care are 

provided for LGBT children and adolescents (Ryan, 2010). 

This new family-oriented approach to services and care 

requires practitioners to proactively engage and work with 

families with LGBT children and adolescents. This includes 

providing accurate information on sexual orientation and 

gender identity for parents and caregivers early in their 

child’s development; engaging, educating, counseling, and 

making appropriate referrals for families with LGBT children; and in particular, helping parents and caregivers who 

react to their LGBT children with ambivalence and rejection 

understand how their reactions contribute to health risks for 

their LGBT children (Ryan & Chen-Hayes, 2013).

The overall objective in helping families learn to support their LGBT children is not to change their values or 

deeply-held beliefs. Instead, practitioners should aim to 

meet parents, families, and caregivers “where they are,” to 

build an alliance to support their LGBT children, and to help 

them understand that family reactions that are experienced 

as rejection by their LGBT child contribute to serious health 

concerns and inhibit their child’s development and wellbeing (Ryan & Diaz, 2011; Ryan & Chen-Hayes, 2013).

Research findings that show the 

critical role of family acceptance 

and rejection – and earlier ages of 

coming out – call for a paradigm 

shift to serve LGBT children and 

adolescents in the context of their 

families.
Aims of resource Guide

This resource guide was developed and is being disseminated 

throughout health and social service systems to help practitioners who work in a wide range of settings to understand the 

critical role of family acceptance and rejection in contributing 

to the health and well-being of adolescents who identify as 

lesbian, gay, bisexual, and transgender. This includes practitioners who work in primary care, behavioral health, schoolbased services, family service agencies, homeless and runaway programs, and foster care and juvenile justice settings. 

Its intent is to help practitioners implement best practices in 

engaging and helping families and caregivers to support their 

LGBT children. The family intervention approach discussed 

in this guide is based on research findings and more than a 

decade of interactions and intervention work by the Family 

Acceptance Project (FAP) at San Francisco State University 

with very diverse families and their LGBT children.

Sexual Orientation – a person’s emotional, sexual, and/

or relational attraction to others. Sexual orientation is usually classified as heterosexual, bisexual, or homosexual 

(lesbian and gay), and includes components of attraction, 

behavior, and identity (Laumann et al., 1994). Sexual orientation is expressed in relationship to others to meet basic 

human needs for love, attachment, and intimacy (Institute 

of Medicine, 2011). Thus, young people can be aware of 

their sexual orientation as feelings of attachment and connection to others before they become sexually active. 

Gender Identity – a person’s internal sense of being 

male, female, or something else. Gender identity is 

internal, so it is not necessarily visible to others. Gender 

identity is also very personal, so some people may not 

identify as male or female while others may identify as 

both male and female.

Gender Expression – the way a person expresses their 

sense of gender identity (e.g., through dress, clothing, 

body movement, etc.). Young children express their 

sense of gender through choices for personal items such 

as toys and clothes, as well as hairstyle, colors, etc.

Gender Non-conforming or Gender Variant – a person 

whose gender expression differs from how their family, 

culture, or society expects them to behave, dress, and act.

Transgender – a person who feels that their gender 

identity does not match their physical body and differs 

from the gender that others observed and gave them at 

birth (assigned or birth gender).

Source: Institute of Medicine, 2011; SAMHSA, 2012

3 A Practitioner’s resource Guide: Helping Families to support their LGBt children

Introduction

A seminal study of LGB identity and adolescent development found that young people report having their first 

“crush” or attraction for another person, on average, at 

around age 10 (Herdt & Boxer, 1993). Subsequent studies on 

LGB youth have reported comparable ages of first awareness 

of sexual attraction (e.g., D’Augelli, 2006; Rosario, Schrimshaw, & Hunter, 2009), and coming out at much younger 

ages than prior generations of LGB adults. Among contemporary youth, researchers from the Family Acceptance 

Project found that adolescents self-identified as LGB, on 

average, at age 13.4. And increasingly, parents and families 

report children identifying as gay at earlier ages – between 

ages 7 and 12. 

Practitioners who work with transgender and gender nonconforming children and youth note that gender identity is 

expressed at early ages (Brill & Pepper, 2008), most often by 

age 3 (Leibowitz & Spack, 2011). As with LGB adolescents, 

the internet and media have significantly increased awareness 

of gender diversity and of the needs and experiences of transgender and gender non-conforming children, adolescents and 

adults. Because children can express a clear sense of gender 

identity at very early ages, many are able to communicate 

their experiences to parents and caregivers, so there is greater 

awareness among some families that a child or adolescent 

might be transgender. As a result, more parents are seeking 

accurate information about gender development and local 

sources of support. 

Still, many families have strict cultural expectations about gender role behavior for males and females and have great difficulty 

tolerating gender non-conforming behavior in their children 

and adolescents (e.g., Malpas, 2011). This includes children and 

youth who are lesbian, gay, and bisexual, as well as heterosexual. A significant number of families have never heard of the 

word transgender and have little understanding of the distress 
that children who are gender non-conforming may experience 

on a daily basis. This may include parents and families who 

have less access to accurate information, based on sociocultural and linguistic backgrounds and/or geographic location.

These early ages of self-awareness and coming out as LGBT 

during childhood and adolescence call for practitioners to expand their approach to care from serving LGBT young people 

either alone as individuals or through peer support to providing 

services and support in the context of their families and caregivers (Ryan & Chen-Hayes, 2013). This need is heightened by 

the lack of available services and trained practitioners to provide family-oriented services and support for LGBT children 

and adolescents across practice disciplines and care settings.

Critical Role of 

Families in Reducing 

Risk & Promoting 

Well-Being

Before research was conducted that included LGBT 

adolescents, parents, foster parents, and other key 

family members, perceptions of how parents and 

families would react to their LGBT children were predominantly negative (Ryan, 2010). However, an in-depth 

study of LGBT adolescents and families found that family 

reactions to their LGBT children were much more varied 

and hopeful than had been previously assumed (Ryan, 2004; 

Ryan & Chen-Hayes, 2013). This study found that: 

• Family reactions to their LGBT adolescents range from 

highly rejecting to highly accepting. Thus, a proportion 

of families respond with acceptance, and more with 

ambivalence, to learning about their child’s LGBT 

identity – and not with uniform rejection as had been 

previously assumed.

“My son is a gift. My role as a 

parent has been to give him 

space to unfold – just as he is – 

into a happy, caring young gay 

man. I’ve learned so much from 

him. He’s helped me grow as a 

parent and as a person.”

Hugo, father of 14-year old gay youth

4 A Practitioner’s resource Guide: Helping Families to support their LGBt children

Introduction

• Rejecting families become less rejecting over time, 

and access to accurate information is a critical factor in 

helping parents, families, and caregivers learn to support their LGBT children. 
• Parents and families want to help their LGBT children 

and to keep their families together, but many do not 

know how.

• Parents and caregivers who are perceived as rejecting their LGBT children and who engage in rejecting 

behaviors (e.g., trying to change their child’s sexual orientation and gender expression) are motivated by care 

and concern for their LGBT children – and by trying to 

help their LGBT child “fit in,” have a “good life,” and 

be accepted by others. 

5 A Practitioner’s resource Guide: Helping Families to support their LGBt children

Critical Role of Families in Reducing Risk & Promoting Well-Being 

“When my daughter was little I 

spent so much time fussing over 

how she looked. I should have 

been concerned about how she 

felt. We didn’t know about transgender – but I know how sad and 

depressed she got right before 

middle school. The school helped 

us find a counselor and that’s 

when we found out how hopeless 

she felt. I wanted to make sure 

she wasn’t rejected by others, but 

instead, I was the one who was 

rejecting her. I’m so grateful I 

could change things before it was 

too late.”

Brianna, mother of 12-year old transgender youth

• Negative outcomes for many LGBT youth, including 

suicide, homelessness, and placement in foster care or 

juvenile justice facilities, can be prevented or reduced if 

parents, families, and caregivers can turn to a knowledgeable source for guidance, accurate information, and 

support. 

• Many parents and families whose children end up out 

of home (e.g., homeless or in custodial care) want to reconnect and to have an ongoing relationship with their 

LGBT children despite assumptions by others that they 

do not want to have any involvement with their LGBT 

children’s lives. 

FAMiLy rejection & HeALtH risKs

(Ryan et al., 2009)

LGBT young adults who reported high levels of 

family rejection during adolescence were:

•	 8.4 times more likely to report having 

attempted suicide

•	 5.9 times more likely to report high levels 

of depression

•	 3.4 times more likely to use illegal drugs, and 

•	 3.4 times more likely to report having engaged 

in unprotected sexual intercourse – 

compared with peers from families that reported 

no or low levels of family rejection

FAMiLy AccePtAnce & WeLL-BeinG

(Ryan et al., 2010)

Family acceptance helps:

•	 protect against depression, suicidal behavior, 

and substance abuse

•	 promote self-esteem, social support, and 

overall health

Research has also found that parents and caregivers play a 

critical role in their LGBT children’s health and well-being 

(e.g., Ryan et al., 2009; Ryan et al., 2010). In particular, 

families help protect against suicidal behaviors (Eisenberg 

& Resnick, 2006; Mustanski & Liu, 2013; Ryan et al., 

2010). Research with LGBT youth and families, foster families, and caregivers has identified more than 100 specific 

ways that parents and caregivers express acceptance and 

rejection of their LGBT children (Ryan, 2009; Ryan, 2010). 

This includes behaviors such as preventing LGBT youth 

from learning about their LGBT identity versus connecting 

them with a positive role model to show them options for 

the future (see Ryan, 2009). These family reactions were 
6 A Practitioner’s resource Guide: Helping Families to support their LGBt children

Critical Role of Families in Reducing Risk & Promoting Well-Being 

then measured in a follow up study of LGBT young adults 

to assess the relationship of family acceptance and rejection 

during adolescence to health and mental health in young 

adulthood.

This research found what many providers have known intuitively for years: that LGBT young people whose parents 

and caregivers reject them report high levels of negative 

health problems (Ryan et al., 2009), and those whose parents 

support them show greater well-being, better general health, 

and significantly decreased risk for suicide, depression, and 

substance abuse (Ryan et al., 2010). Additional research from 

this project provides key information on school-based and 

faith-based experiences, including the relationship between 

condemnation, victimization, and support of LGBT adolescents and their health and well-being in young adulthood. 

I

Working closely with many racially and ethnically diverse 

families, LGBT youth, and young adults in applying this 

research showed that families – even those who were very 

rejecting – could learn to modify rejecting behavior and 

increase support for their LGBT children. This requires practitioners to provide education, guidance, and support in ways 

that resonate for them (Ryan, 2010). Several years of intervention and resource development work has led to the generation of a series of multicultural family education materials; 

research-based family intervention videos; assessment tools; 

and intervention strategies to help diverse families support 

their LGBT children (see Resources, p. 12).

Grounded in a strengths-based perspective, this family 

intervention framework (Ryan & Chen-Hayes, 2013; Ryan 

& Diaz, 2011) views families and caregivers as potential 

allies in reducing risk, promoting well-being, and creating a 

healthy future for their LGBT children. This approach views 

the family’s cultural values – including deeply-held beliefs – 

as strengths. Research findings are aligned with underlying 

values to help families understand that it is specific behaviors and communication patterns that contribute to both their 

LGBT child’s risk and their well-being. In expanding their 

frame to proactively engage and work with families, practitioners may find the assumptions in Figure 1 useful to build 

an alliance and to help parents, foster parents, families, and 

caregivers to support their LGBT children.

FiGure 1

FAMiLy AccePtAnce Project – core AssuMPtions

(Ryan & Diaz, 2011)

• Assumes that families love their children and want them to have a good life. At the same time, we acknowledge that 

their hopes and dreams for their children’s future are shaped by cultural and religious beliefs that may be at odds 

with their child or adolescent’s sexual orientation and gender identity/expression. 

• Meets families where they are. This includes starting at the family’s level of knowledge, expectations, and beliefs 

about their child’s sexual orientation and gender identity/expression. 

• Uses a strengths framework to align our research findings, education and prevention messages, and family support 

approach with the parents’ and caregivers’ values about family, and the role of family in their culture and religious 

practice. 

• Supports the need for families to be heard and understood. A critical aspect of our work is to provide a nonjudgmental space where parents and caregivers can tell their story and share their experiences and expressions of care and 

concern for their children’s well-being that are rooted in culture, values, and specific beliefs such as faith traditions.

 
7 A Practitioner’s resource Guide: Helping Families to support their LGBt children

Critical Role of Families in Reducing Risk & Promoting Well-Being 

FiGure 1, continued

FAMiLy AccePtAnce Project – core AssuMPtions

(Ryan & Diaz, 2011)

• Recognizes that parents and caregivers who are seen as rejecting their LGBT child are motivated by care and concern to help their child “fit in,” have a “good life,” and be accepted by others. 

• Understands that family behaviors are not isolated incidents, but occur in a cultural context aimed at socializing their 

children and adolescents to adapt and be successful in a hetero-normative (heterosexual) society. These family behaviors aim to protect their children from harm, including victimization due to their LGBT identity and gender expression.

• Uses FAP research findings to link family reactions to their child’s LGBT identity with health, mental health, and wellbeing. Beyond building a strong alliance between families and providers, family awareness of the consequences of 

their behavioral reactions is the most important mechanism of change.

• Understands that parents and families experience their lack of knowledge about LGBT issues as inadequacy that 

feels disempowering and shameful. Many families perceive their children’s LGBT identity as a loss, particularly as 

a loss of control over their children’s future. Providers should help families validate and address these feelings by 

affirming the importance of family support to build their child’s self-esteem, to promote their child’s well-being, and to 

buffer rejection and negative reactions from others. 

• Recognizes that when rejecting and accepting behaviors co-exist, parents and caregivers experience ambivalence, 

and their struggle to validate their LGBT child results in decreased support and increased risk. Education and learning how their reactions affect their LGBT children can improve communication and help parents and caregivers 

respond in ways that help their LGBT child feel supported and loved rather than misunderstood or rejected.

From: Family Acceptance Project: Intervention guidelines and strategies by Caitlin Ryan and Rafael Diaz. San Francisco: Family 

Acceptance Project, 2011. Copyright © 2011 Caitlin Ryan, PhD. Reprinted with permission.
8 A Practitioner’s resource Guide: Helping Families to support their LGBt children

Helping Families 

Decrease Risk & 

Increase Well-Being for 

Their LGBT Children

Beyond building an alliance and showing families 

that a practitioner respects their values and beliefs, 

the primary mechanism for change is helping families understand that there is a powerful relationship between 

their words, actions, and behaviors and their LGBT child’s 

risk and well-being. Parental and caregiver reactions to an 

LGBT child or adolescent also affect their whole family.

“When I put my head on the pillow 

at night, I think about my daughter and just hope she’s safe. I 

don’t know where she is. I haven’t 

heard from her since I threw her 

out of the house when she told 

me she was lesbian. I didn’t know 

what to do. I wish I had acted differently. I would give anything to 

be able to change that now.”

Monica, mother of 16-year old lesbian youth

Families respond to their LGBT children based on what 

they know, what they hear from their family, clergy, close 

friends, and information sources, including providers who 

may also have misinformation about sexual orientation and 

gender identity, especially in childhood and adolescence. As 

a result, parents and families who believe that homosexuality and gender non-conformity are wrong or are harmful for 

their LGBT children may respond in a variety of ways to try 

to prevent their children from becoming gay or transgender. 

This may include: preventing their child from having 

an LGBT friend, learning about their LGBT identity, or 

participating in a support group for LGBT youth (such as a 

Gay Straight Alliance or school diversity club), or excluding 

their child from family events and activities. Families and 

caregivers who respond in these ways do so without understanding that these reactions are experienced as rejection by 

their LGBT children and that they are significantly related 

to attempted suicide and other serious health concerns for 

LGBT young people (e.g., Ryan, 2009). 

Parents and families who engage in these behaviors are 

typically motivated by helping their children and protecting them from harm. In this case, families are trying to 

prevent their children from adopting what they perceive as 

a “lifestyle” or “choice” that they believe will hurt them. 

Understanding that specific reactions that parents and 

families think are caring but that LGBT youth experience as 

rejecting and harmful – and that contribute to serious health 

problems – helps motivate parents, families, and caregivers to modify and stop rejecting behaviors, to support their 

LGBT children (Ryan, 2009; Ryan & Diaz, 2011).

 

Approach to Working with Families

Several key approaches can help families learn to support their LGBT children, across a wide range of practice 

settings and service systems (Ryan & Diaz, 2011). These 

include the following:

Engage, approach, and connect with families and caregivers by meeting them “where 

they are,” and view each family as an ally. 

Each family brings different dynamics, experiences, and 

strengths to learning that their child is lesbian, gay, bisexual, 

or transgender. Some families can quickly learn to support their LGBT children. Some were accepting before they 

knew or perceived that their child was LGBT. Others need 

individual support to adjust to having a gay or transgender 

child. Some need counseling, and others may need family 

therapy. 
9 A Practitioner’s resource Guide: Helping Families to support their LGBt children

Helping Families Decrease Risk & Increase Well-Being for Their LGBT Children

 

 

 

 

 

All families need education about how family reactions relate 

to their LGBT children’s health and well-being. Families who 

are accepting are eager to learn new ways of supporting their 

LGBT children. For most families, learning about specific behaviors to protect and support their LGBT children will be new 

information. In addition, many families who believe they are 

accepting are actually ambivalent about their 

child’s sexual orientation and gender identity. 

Rather than expressing support, these families 

are instead giving their child mixed messages 

that contribute to health risks and diminished 

self-esteem. 

Family rejection & risk for suicide

LiFetiMe suicide AtteMPts By LGBt younG AduLts 

rejected By FAMiLies in AdoLescence 

Ages 21-25

Level of Family Rejection

LOW

rejection

MODERATE

rejection

HIGH

rejection

Source: Supportive Families, Healthy Children: Helping Families with Lesbian, Gay, 

Bisexual & Transgender Children by Caitlin Ryan, Family Acceptance Project, San Francisco State University, 2009. Copyright © Caitlin Ryan, PhD. Reprinted with permission.

Family rejection & risk for HiV

Level of Family Rejection

LOW

rejection

MODERATE

rejection

HIGH

rejection

Source: Supportive Families, Healthy Children: Helping Families with Lesbian, Gay, 

Bisexual & Transgender Children by Caitlin Ryan, Family Acceptance Project, San Francisco State University, 2009. Copyright © Caitlin Ryan, PhD. Reprinted with permission.

Let parents and caregivers tell 

their story. 

Research and intervention work has found 

that few parents and caregivers have had the 

opportunity to talk about their experiences, 

concerns and hopes for their LGBT child 

with a supportive, nonjudgmental professional (Ryan & Chen-Hayes, 2013). Parents and 

caregivers also need to express their anxieties and fears about how others might treat or 

hurt their LGBT child. This step is critical 

to building an alliance and to understanding 

their perspective. 

Give families respectful language to talk 

about sexual orientation and gender identity. 

Most families and many providers lack understanding of 

normative development of sexual orientation and gender 

identity in children and adolescents. Many families and 

caregivers have not talked about these issues in a way that 

is not disparaging. For others, cultural silence 

about homosexuality is the norm, and talking 

about these issues may feel shameful and 

uncomfortable. 

FAP has developed research-based multicultural education resources to teach providers 

how to talk about these issues with families, to 

educate families on sexual orientation and gender identity, and to show them ways to help and 

support their LGBT children (see Resources, 

p. 12). These materials were developed with 

extensive guidance from families, LGBT youth 

and informed linguists and literacy experts 

to use language that is not derogatory and 

is readily understood and respectful, to help 

parents and families understand new research 

on family reactions and adjustment to having 

an LGBT child. For some families, these topics 
are distressing and may never have been discussed in a neutral 

way. Helping families start to frame these issues differently 

will enable them to talk about them with their LGBT children. 

Talking with their LGBT child about their child’s identity (even 

when they are uncomfortable) is a supportive behavior that 

helps protect against risk and promote well-being (Ryan, 2009).

10 A Practitioner’s resource Guide: Helping Families to support their LGBt children

Helping Families Decrease Risk & Increase Well-Being for Their LGBT Children

“I didn’t understand how hurtful 

it was to tell my son that being 

bisexual was just a fad. I pushed 

him away when he was trying to 

share an important part of himself with me. I didn’t understand 

about sexual orientation – 

I thought I could pressure him to 

be straight. But instead, I made 

him think I was rejecting him. I’ve 

spent a lot of time listening to 

him now – and learning.”

Ben, father of 14-year old bisexual youth

Educate families on how family rejecting 

behaviors affect their LGBT child. 

This approach has found that helping parents and families 

understand the serious health risks related to family rejection 

lays the groundwork to focus on reducing their LGBT child’s 

risk, to provide support and to accept their LGBT child (see 

Resources, p. 12). For families that are rejecting and ambivalent, in particular, learning that behaviors they thought 

were helping their child are instead putting their child at risk 

is sobering, disturbing, and even shocking. This includes 

common rejecting behaviors such as trying to discourage 

or change their child’s sexual orientation or gender expression or blaming them when others mistreat them because 

of their LGBT identity. Few parents and families want to 

intentionally hurt their LGBT children, and learning about 

this research helps parents understand their critical role in 

protecting their child from harm. It also helps 

them understand how these rejecting behaviors contribute to family conflict.

Educate families on how supportive and accepting behaviors affect their LGBT child. 

Families typically think that loving their child 

will build their child’s self-esteem and protect 

them from harm. However, it is how parents, 

foster parents, and caregivers treat or respond 

to their LGBT children that matters. In other 

words, the specific behaviors that families 

and caregivers engage in – or how they love 

their LGBT children – contribute to serious 

health risks or help protect them from harm 

and promote their well-being.

More than 50 family accepting behaviors were 

identified that are related to better overall 

health, higher self-esteem and significantly lower levels of depression, suicidal behavior, and substance abuse (Ryan et al., 

2010). These include a range of behaviors such as supporting their child’s gender expression, welcoming their child’s 

LGBT friends to family events and activities, and helping 

their congregation become more welcoming of LGBT people 

(for information on key behaviors, see Ryan, 2009).

FAMiLy AccePtAnce durinG AdoLescence & 

PercePtions oF BeinG A HAPPy LGBt AduLt

Level of Family

Acceptance

EXTREMELY

accepting 92%

VERY

accepting 77%

A LITTLE

accepting 59%

NOT AT ALL

accepting 35%

Source: Supportive Families, Healthy Children: Helping Families with Lesbian, Gay, 

Bisexual & Transgender Children by Caitlin Ryan, Family Acceptance Project, San Francisco State University, 2009. Copyright © Caitlin Ryan, PhD. Reprinted with permission.
Framing for Families that Are struggling 

or uncertain about Having an LGBt child

Practitioners should help parents and caregivers separate their 

personal reactions to having an LGBT child from their child’s 

need for love, safety, and support. For families that are struggling and may initially be rejecting or ambivalent, specific 

framing discussed below can help parents and caregivers 

provide support while integrating their child’s sexual orientation, gender identity, and gender expression with their values, 

perceptions, and beliefs (Ryan, 2009; Ryan & Rees, 2012). 

This framing includes the following: 

 

Families that don’t accept their children’s 

sexual orientation and gender identity can still 

support their LGBT children and decrease rejecting behaviors to protect them from harm. 

Parents and caregivers who believe that homosexuality or 

gender non-conformity are wrong can still support their 

gay or transgender child by modifying or changing rejecting behaviors that increase their LGBT child’s risk, without 

accepting an identity they think is wrong. FAP has been 

developing specific family education materials and approaches to help families support their LGBT children while 

maintaining their values and deeply-held beliefs (e.g., Ryan 

& Rees, 2012). 

A little change makes a difference in decreasing family rejecting behaviors and in 

increasing support for their LGBT children. 

Research shows that high, moderate, and low rejection are 

related to dramatically varying levels of risk. For example, 

LGBT youth from highly rejecting families were 8.4 times 

more likely to report having attempted suicide at least once 

by young adulthood, while those from families that were 

moderately rejecting were twice as likely to attempt suicide 

(compared with peers who reported no or low levels of 

specific family rejecting behaviors) (Ryan et al., 2009). 

Similarly, nearly all young adults who reported high levels 

of family acceptance believed they could have a good life as 

an LGBT young adult, compared with only about 1 in 3 of 

their peers who reported no acceptance from their family or 

caregiver during adolescence (Ryan, 2009). Perceptions of 

the future are very important for self-care, for health promotion, for decreasing risk-taking, and for career and personal 

aspirations.

11 A Practitioner’s resource Guide: Helping Families to support their LGBt children

Helping Families Decrease Risk & Increase Well-Being for Their LGBT Children

Increasing Family 

Support: How to 

Help Right Now

Given the early ages of coming out and the critical need for family education and guidance, the dearth of targeted 

services to help diverse families support their LGBT children is a significant barrier to addressing the prevention, 

care, and support needs of LGBT children and adolescents. Until such services are widely available, practitioners 

and agencies can take several basic steps to respond to these needs in the following ways (Ryan & Diaz, 2011):

• Provide training on engaging and supporting families with LGBT children for all practitioners and agencies that work 

with children, youth, and families (see Resources, p. 12). 
12 A Practitioner’s resource Guide: Helping Families to support their LGBt children

Increasing Family Support: How to Help Right Now 

• Include LGBT young people and families when describing populations served in agency literature, brochures, outreach 

activities, and websites to ensure that LGBT youth and families know that your agency welcomes them and will provide 

services for them. 

• Include information on the importance of family support and on the relationship between family acceptance and rejection 

and health risks and well-being for LGBT youth in all parent and caregiver education resources, activities, and programs.

• Ask adolescent patients and clients about their sexual orientation and gender identity.1 Ask about family reactions to 

their sexual orientation, gender identity, and gender expression, including specific behaviors that parents, families, and 

caregivers use to respond to their child’s sexual orientation and gender expression.2

• Provide education, support, and counseling to parents, families, foster parents, and caregivers who are engaging in rejecting behaviors. This includes using educational materials to help them understand the impact of their behaviors on their 

LGBT child (see Resources below), and providing coaching, counseling, peer support, and family therapy.

• Include families and caregivers of LGBT children and youth on advisory groups for child, youth, and family service 

programs and agencies.

• Do outreach to invite and include families and caregivers of LGBT children and youth and their LGBT children in recreational, social, and community activities and events offered by practitioners, programs, and agencies that serve children, 

youth, and families.

• Include LGBT books, brochures, and posters in agency waiting rooms, offices, and care facilities. Many LGBT youth and 

those who may be questioning their identity look for “safe zone” or rainbow stickers to indicate that a provider will be 

open and respectful in providing support and addressing needs related to their LGBT identity.

Resources for

Practitioners 

and Families

The Family Acceptance Project has worked with 

many racially and ethnically diverse families, LGBT 

youth, and young adults, and the practitioners who 

care for them, to develop a series of multicultural family 

education and guidance materials and assessment tools. 

Information is available at: http://familyproject.sfsu.edu/

These include:

Family Education Booklets – research-based guidance 

materials that educate families, caregivers, and providers on 

how family acceptance and rejection relates to health and 

well-being for LGBT young people to help increase family 

and caregiver support for LGBT children and youth. Currently available in English, Spanish, and Chinese, and some 

faith-based versions; new versions are in development, 

including low literacy, in other languages, and for families 

from a range of faith backgrounds. These booklets are designated as a “Best Practice” for suicide prevention for LGBT 

people by the Suicide Prevention Resource Center/American 

Foundation for Suicide Prevention Best Practices Registry.
13 A Practitioner’s resource Guide: Helping Families to support their LGBt children

Resources for Practitioners and Families 

Family Education Videos – compelling short documentaries that show the journey of ethnically and religiously 

diverse families from struggle to support of their LGBT 

children, to give LGBT youth and families hope and to 

show the process that helps families learn to support their 

LGBT children. Designed to educate families, LGBT children, and youth, for community education, and for provider 

training, these videos are based on research and practice 

with LGBT youth and families from the Family Acceptance 

Project.

Assessment and Training – a research-generated screening 

instrument (the FAPrisk Screener) was developed based on 

findings from FAP studies to quickly identify LGBT youth 

who are experiencing rejection from parents, foster parents, 

and caregivers, with guidance to inform family interventions 

and follow up care, including preventing homelessness and 

placement in custodial care (Ryan & Monasterio, 2011). 

The screener is highly predictive of health concerns related 

to family rejection, including depression, suicide attempts, 

substance use problems, and diagnosis with a sexually transmitted disease.

Training is available on using the screener and using family 

education materials and family engagement and intervention 

strategies.

E

1

 Experts on care of LGBT children and youth in child welfare have developed guidelines for managing information 

about a young person’s sexual orientation, gender identity, 

and expression which can help practitioners think about 

these issues and provide guidance for asking young people 

about their identities (see Wilber, 2013). In addition, many 

health professional disciplines have directed their members 

to ask adolescents about their sexual orientation, including the American Medical Association, which included a 

directive to ask adolescents about their sexual orientation 

20 years ago (e.g., Elster & Kuznets, 1994). Major health 

professional associations routinely update standards of care 

and policy statements on care of LGBT youth and adults.

2

 The Family Acceptance Project has developed a clinical 

assessment screening tool and training to help practitioners 

quickly identify LGBT young people who are experiencing 

various levels of family rejection and to help practitioners 

develop a follow up plan to engage families to decrease 

rejecting behaviors that are related to significantly increasing their LGBT children’s risk for serious negative health 

problems (e.g., suicide, substance abuse, HIV, etc.) and 

which can precipitate ejection and removal from the home 

(see Ryan & Monasterio, 2011).
14 A Practitioner’s resource Guide: Helping Families to support their LGBt children

References

Bouris, A., Guilamo-Ramos, V., Pickard, A., et al. (2010). A 

systematic review of parental influences on the health and 

well-being of lesbian, gay, and bisexual youth: Time for a 

new public health research and practice agenda. Journal of 

Primary Prevention, 31, 273–309.

Brill, S. A., & Pepper, R. (2008). The transgender child: 

A handbook for families and professionals. Berkeley, CA: 

Cleis Press.

D’Augelli, A. R. (2006). Developmental and contextual 

factors and mental health among lesbian, gay, and bisexual 

youths. In A. M. Omoto & H. S. Kurtzman (Eds.), Sexual 

orientation and mental health: Examining identity and 

development in lesbian, gay, and bisexual people (pp. 37-

53). Washington, DC: American Psychological Association.

Diamond, L. M., Butterworth, M. R., & Allen, K. (2012). 

Sexual-minority development in the family context. In P. K. 

Kerig, M. S. Schulz, & S. T. Hauser (Eds.), Adolescence and 

beyond: Family processes and development (pp. 249-267). 

New York, NY: Oxford University Press. 

Eisenberg, M. E., & Resnick, M. D. (2006). Suicidality 

among gay, lesbian and bisexual youth: The role of 

protective factors. Journal of Adolescent Health, 39, 662–

668.

Elster, A. B., & Kuznets, N. J. (1994). Guidelines for 

adolescent preventive services. Baltimore: Williams and 

Wilkins.

Herdt, G. H. & Boxer, A. (1993). Children of horizons: 

How gay and lesbian teens are leading a new way out of the 

closet. Boston, MA: Beacon Press.

IOM (Institute of Medicine). (2011). The health of 

lesbian, gay, bisexual, and transgender people: Building a 

foundation for better understanding. Washington, DC: The 

National Academies Press.

Laumann, E. O., Gagnon, J. H., Michael, R. T., & Michaels, 

S. (1994). The social organization of sexuality: Sexual 

practices in the United States. Chicago, IL: University of 

Chicago Press. 

Leibowitz, S. F., & Spack, N. P. (2011). The development 

of a gender identity psychosocial clinic: Treatment issues, 

logistical considerations, interdisciplinary cooperation, and 

future initiatives. Child and Adolescent Psychiatric Clinics 

of North America, 20, 701–724.

Malpas, J. (2011). Between pink and blue: A multidimensional family approach to gender nonconforming 

children and their families. Family Process, 50(4), 453–470. 

Mustanski, B., & Liu, R. T. (2013). A longitudinal study of 

predictors of suicide attempts among lesbian, gay, bisexual 

and transgender youth. Archives of Sexual Behavior, 42, 

437-448.

Resnick, M. D., Bearman, P. S., Blum, R. W., et al. (1997). 

Protecting adolescents from harm. Findings from the 

National Longitudinal Study on Adolescent Health. Journal 

of the American Medical Association, 278(10), 823–832.

Rosario, M., Schrimshaw, E. W., & Hunter, J. (2009). 

Disclosure of sexual orientation and subsequent substance 

use and abuse among lesbian, gay, and bisexual youths: 

Critical role of disclosure reactions. Psychology of Addictive 

Behaviors, 23(1), 175-184.

Ryan, C. (2010). Engaging families to support lesbian, 

gay, bisexual and transgender (LGBT) youth: The Family 

Acceptance Project. The Prevention Researcher, 17(4), 11-

13.

Ryan, C. (2004). Families of lesbian, gay and bisexual 

adolescents. Current Problems in Pediatric and Adolescent 

Health Care, 34(10), 369-375.

Ryan, C. (2009). Supportive families, healthy children: 

Helping families with lesbian, gay, bisexual & transgender 

children. San Francisco, CA: Family Acceptance Project, 

Marian Wright Edelman Institute, San Francisco State 

University.
15 A Practitioner’s resource Guide: Helping Families to support their LGBt children

References

Ryan, C., & Chen-Hayes, S. (2013). Educating and 

empowering families of LGBTQ K-12 students. In E. S. 

Fisher & K. Komosa-Hawkins (Eds.), Creating school 

environments to support lesbian, gay, bisexual, transgender, 

and questioning students and families: A handbook for 

school professionals (pp. 209-227). New York, NY: 

Routledge. 

Ryan, C., & Diaz, R. (2011). Family Acceptance Project: 

Intervention guidelines and strategies. San Francisco: 

Family Acceptance Project.

Ryan, C., & Monasterio, E. (2011). Provider’s guide for 

using the FAPrisk screener for family rejection & related 

health risks in LGBT youth. San Francisco, CA: Marian 

Wright Edelman Institute, San Francisco State University.

Ryan, C., & Rees, R. A. (2012). Supportive families, healthy 

children: Helping Latter-day Saint families with lesbian, 

gay, bisexual & transgender children. San Francisco, 

CA: Family Acceptance Project, Marian Wright Edelman 

Institute, San Francisco State University.

Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009). 

Family rejection as a predictor of negative health outcomes 

in white and Latino lesbian, gay and bisexual young adults. 

Pediatrics, 123(1), 346-352.

Ryan, C., Russell, S. T., Huebner, D. M., Diaz, R., & 

Sanchez, J. (2010). Family acceptance in adolescence and 

the health of LGBT young adults. Journal of Child and 

Adolescent Psychiatric Nursing, 23(4), 205-213.

Substance Abuse and Mental Health Services 

Administration. (SAMHSA). (2012). Top health issues 

for LGBT populations information & resource kit. HHS 

Publication No. (SMA) 12-4684. Rockville, MD: Substance 

Abuse and Mental Health Services Administration.

Wilber, S. (2013). Guidelines for managing information 

related to the sexual orientation and gender identity and 

expression of children in child welfare systems. Oakland, 

CA: Putting Pride Into Practice Project, Family Builders by 

Adoption.
HHs Publication no. PeP14-LGBtKids