This document discusses issues related to providing competent healthcare to lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth. It identifies some of the key risk factors LGBTQ youth face like marginalization and increased health risks. It also discusses how lack of provider training and homophobia can negatively impact LGBTQ health outcomes. The document provides guidance on creating an LGBTQ-affirming clinical environment including ensuring confidentiality, using inclusive forms and language, and displaying supportive materials. It also offers suggestions for discussing sensitive topics like gender identity, sexual orientation, and sexuality with LGBTQ youth patients.
2.
Objectives
Identify three risk factors faced by LGBTQ youth
Discuss the ways that homophobia contributes to
LGBTQ health outcomes
List three elements of LGBTQ-competent health
care delivery
Describe resources for LGBTQ youth
3.
What Is Healthy Sexuality?
Sexual development and growth is a
natural part of human development
Healthy sexual expression is
different than sexual risk
Same-sex sexual behavior is included
in the realm of healthy sexuality
4.
Why Is Training for LGBTQ
Youth-Competent Care Important?
Youth and LGBTQ community are marginalized,
have increased health risks
Providers rarely receive LGBTQ-specific training
Providing LGBTQ youth-competent care is a skill
National, statewide, and city initiatives to improve access to
health care for LGBTQ youth
ACA may increase number of previously uninsured,
disproportionately LGBTQ and/or adolescents
5. Case: Joseph
Joseph is a 13-year-old
male who comes to the
clinic with his mother. She
is concerned that:
Most of his friends are
girls.
He is drawn to
traditionally feminine
activities.
She caught him wearing
his sister’s clothes.
8.
Creating a Safe Space
Train all staff
Assure
Confidentiality
Display LGBTQ-
affirming
materials
Provide support
resources
Zero tolerance
for insensitivity
11. What Do the Mother’s Concerns
Reveal?
Very little
Joseph may be
questioning his sexuality
and/or gender identity but
dress and other outward
appearances do not
indicate sexual
orientation or identity
13.
Spectrum of
Gender and Sex
Natal
Gender/Anatomy
Male
Gender Identity
Feminine
Male
Gender Expression
Female
Masculine
Heterosexual Homosexual
Sexual Orientation
Female
14.
By age 4
Gender identity is stable
Recognize that gender is constant
At 3 years old
Can label themselves as girl or boy
Between ages 1 and 2
Conscious of physical differences
between sexes
Awareness of Gender Identity
15.
Prevalence/Stability of Gender Identity
Data depends on definition, populations, culture
Gender variant 1:500
Transitioned 1:20,000
Development considerations
Many children 5-12 years with gender dysphoria do not
continue to suffer as adolescents
Some identify as homosexual or bisexual
• Natal males: 63% to 100%
• Natal females: 32% to 50%
18.
Ask: When you think of yourself as a person, do
you think of yourself as male, female, somewhere
in between, or another gender?
Approaching Gender Identity with
Adolescent Patients
19.
Terminology: What’s in a Name?
Transgender = umbrella term for individuals & communities.
A person whose identity does not conform unambiguously to
conventional notions of male or female gender roles, but blends or
moves between them.
Gender nonconforming = individuals who do not follow other
people’s ideas or stereotypes about how they should look or act
based on the female or male sex they were assigned at birth.
Cisgender = a person whose gender identity conforms
unambiguously to conventional notions of gender, and matches
their natal/biologic gender
21.
Identities and Transition
Transition
Process and time when person goes from living as one
gender to living as another gender
Identities include but are not limited to:
MTF = male to female,
transgender woman
FTM = female to male,
transgender man
22.
Case: Joseph
Joseph tells you that he is not sure if he thinks of
himself as a girl or a boy.
He feels “okay” with this but it makes him sad that his
mother is so upset with him.
What can you do?
23.
Offer yourself and other
community organizations as
resources
Explain that many teens explore
gender roles and norms
Joseph’s mother’s concerns
Gender Interview Skills
Ask Joseph if it is okay for you
to speak with his mother
Ask
Permission:
Validate:
Reassure:
Identify
Resources:
24.
Key Points
Prepubertal gender nonconformity may eventually
evolve in a variety of gender and sexual expressions
Peripubertal gender nonconformity is more
predictable and less to change
Gender dysphoria for DSM-5 coding (not gender
identity disorder)
Gender care may be better served using a
developmental perspective
25.
Case: Sophia
Sophia is a 16-year-old female who comes to the
clinic for a physical
She indicates she is having sex but not using
contraception on her intake form
How do you discuss sensitive issues
with young patients?
26. Comprehensive HEEADSSSS
• Is a tool to be used to stimulate dialogue rather than a
checklist
• Ask sensitive questions later in the interview
• This may be the time to ask parents to leave the room
• “I ask all my patients the following questions”
• Consider starting at 13 y/o
H: Home
E: Education/Employment
E: Eating
A: Activities
D: Drugs
S: Sexuality
S: Suicide/depression
S: Safety
S: Spirituality/Strengths*
HEADS model allows
patient to be validated as
a person rather than
focusing just on their
risks
25
27.
Case: Sophia
As you begin the sexual
interview, Sophia discloses that
she self-identifies as a lesbian.
29.
Sexual Attraction Questions
Are you attracted to:
Different sex
Same sex
Both or all sexes
Neither
Not sure yet
How comfortable do you feel with this/these attractions?
Have you told your family or friends about this/these attractions?
30.
Sexual Orientation Defined
Refers to an
individual’s pattern
of physical and
emotional arousal
toward other people
Heterosexual—straight
Homosexual—gay,
lesbian
Bisexual
Pansexual
Queer
Other
31.
Determinants of Sexual Orientation
Sexual orientation is not a “choice”
Most likely determined by combination of influences:
Genetic, hormonal, environmental
More important to focus on
Sexuality, relationships, intimacy is an
expected part of development
How does patient feel about their sexuality?
How does family or community support this aspect of
selfhood?
32.
Awareness of Sexual Orientation
First awareness of homosexual attraction occurred
at:
~9 for males
~10 for females
Studies indicate many LGB youth self-identify at age
~16
For some, internal coming-out process does not
occur until later in life
33.
Assessing Sexual Orientation and Same-
Sex Behavior Among Teens
Lack of nationally representative surveys assessing
sexual orientation/same-sex behaviors
Prevalence of LGBTQ youth difficult to ascertain
Addressed in some youth risk behavior surveys
Not in National YRBS
12 states and the District of Columbia include such
questions
• Inconsistency in question content by state
• Inconsistency in question(s) asked each year
34.
Trends in Assessing LGBT Students
0
1
2
3
4
5
6
7
8
9
10
1995 1997 1999 2001 2003 2005 2007 2009
Self Reported Sexual
Orientation
Gender of Sexual
Partners/Contacts
Harrassment Due to Perceived
Sexual Orientation
Number of States* Asking About Sexual Orientation Over Time, by
Question
*Note: District of Columbia was counted as a state in the above
gaydata.org 2010
36.
MN HS 1990s: Another Student
Sample
35,000 12- to 18-
year-olds surveyed
in Minnesota
88.2%:
predominantly
heterosexual
1.1%:
bisexual or
predominantl
y homosexual
10.7% “unsure”
Increase in
homosexual
attraction with
increased age
2.2% age 12;
5.9% age 16;
6.4% age 18.
37.
Case: Sophia
Sophia self-disclosed her sexual
orientation.
If she had not, would you
approach this topic with your
patient?
38.
Discuss Sexuality in Clinical
Encounters
Due to discrimination and fear, many LGBTQ youth
have difficulty accessing health care
Most LGBTQ youth are “invisible” and often will not
raise issue until asked
Asking normalizes notion that there is a range of
sexual orientations and gender identities
39. Asking about Sexual Attraction
How can you respectfully ask
about sexual orientation?
If you had a crush on
someone, would it be a
boy, girl, neither
or both?
Are you sexually attracted
to guys, girls, or both?
When you think of yourself
in a relationship is it with a
guy, a girl, or both?
40.
Asking About Sexual Behaviors
Need to be sensitive AND specific
Younger kids
• Have you held hands or cuddled?
• Have you kissed or touched each other’s private parts?
• ……
Older teens
• Have you ever had: oral sex, vaginal sex, anal sex?
• What parts went where?
• Did you put your penis in his/her vagina, butt, or mouth?
• Did you take his/her penis in your vagina, butt, or mouth?
41.
Avoid Assumptions
Don’t assume:
Patients are heterosexual
Bisexuality is a phase
Sexual orientation based on gender of partner
Sexual orientation or gender identity based on
appearance
Sexual orientation or gender identity is the same as
last visit
LGBTQ patients are engaging in risky behavior
LGBTQ patients have unsupportive families
42.
Barriers to Care: Medical Training
Most medical schools neglect LGBT issues
One study found that most medical schools devoted
5 hours or less to teaching anything more than
asking, “What is the gender of your sexual partner?”
One-third of medical schools assigned no time at all
to LGBT topics
43.
Barriers to Care: Provider Attitude
Lambda Legal survey through partner organizations,
4,916 LGB respondents, 2009
Almost 8% of LGB and 27% of transgender and gender
nonconforming reported being denied care because of
their identity/orientation
11% reported that providers refused to touch them or
used excessive precautions
Transgender and gender-nonconforming respondents
reported facing discrimination and barriers to care 2-3
times more frequently than LGB respondents
16. Lambda Legal (2010)
44.
Consequences of Barriers
1 out of 2 LGBT adults withheld their sexual orientation
from a provider
1 of 4 withheld information about sexual practices (5
times more than heterosexual peers)
Harris Poll (2002 & 2003). Gran JM et al (2011). Krehely J (2009).
46.
Patient “Coming Out”—What Next?
Assess comfort with feelings
Identify to whom (if anyone) the patient has
disclosed the information
Counsel regarding consequences of disclosure to
family, friends, etc.
Discuss ways to facilitate communication with
parents
47.
Coming Out—LGB Youth
Sexual minority youth are coming out at younger
ages
Human Rights Campaign
• 10,000 13- to 17-year-olds in 2012
Awareness of same-sex attraction is age 9
Disclosure is at age 16 years*
Each youth has unique experience
Time in development
Exploration
Risk taking
Added support
49.
Possible Negative Outcomes
of “Coming Out”
HEADSSS Screen for…
Family discord and rejection
Religious condemnation
Runaway, homelessness
School, peer, work problems
Social stigma
Isolation
Victimization & physical violence
Risk-taking
Sex behaviors
Drug use
Depression, suicide
50.
LGB Prevalence (YRBS 2001–2009)
Sexual
Identity
Percentage Median
Number in
Pediatric
Practice*
Heterosexu
al
90.3–93.6 93% 620-775
Gay/Lesbian 1.0–2.6 1.3% 9–11
Bisexual 2.9–5.2 3.7% 25–31
Unsure 1.3–4.7 2.5% 17–21
*Average pediatrician has a panel of 2,000 to 2,500
patients. Typically, 30% are age 12 or older
53.
Barriers to LBBTQ-Sensitive
Adolescent Health Care
LGBTQ patients experience discrimination
Many providers not comfortable treating LGBTQ
youth
Almost 8% of LGB and 27% of transgender and gender
nonconforming reported being denied care because of
their identity/orientation
Exacerbated by barriers to general adolescent care
Unable to use insurance, lack of insurance and/or fear
of disclosure
Lack of access to appropriate SRH information
Adolescents think they are invincible
54.
Homophobia as a Barrier to Health
Care
Perceived lack of confidentiality
Fear of health care provider reaction upon
disclosure
Provider’s assumption of heterosexuality
Internalized shame and/or guilt
55.
Relationship between Homophobia/Transphobia
and Health Outcomes
Impact of
homophobia/
transphobia
Internalizing effects
of homophobia/
transphobia
Decreased
access to
competent
health
services
Poor health and
psychological
outcomes
*Where culturally
competent medical
and mental health
care can be a
mitigating factor
*
*
* *
5. O’Hanlan, et al (1997)
57.
Effects of Homophobia
Youth may internalize
societal homophobia
leading to
Decreased sense of self-worth
Self-medication and substance
abuse
Shame
Risk-taking behavior
Suicidality
58.
Substance Abuse
In the last 30 days,
LGBTQ youth are more
likely to have used:
Tobacco
59.3% vs. 35.2%
Alcohol
89.4% vs. 52.8%
Cocaine
25.3% vs. 2.7%
LGBTQ youth are more
likely to have used
substances
before the age of 13:
Tobacco
47.9% vs. 23.4%
Alcohol
59.1% vs. 30.4%
Cocaine
17.3% vs. 1.2%
59.
Mental Health
2-7 times more likely to attempt suicide
~2 times as likely to report depression
Young MSM are more likely to suffer body image
dissatisfaction and disordered eating behaviors
60.
Homelessness
Studies have reported
that Sexual Minority
Homeless Youth have
Lifetime sexual partners
Rates of HIV/STIs
Younger Ages of Sexual Initiation
30-40% of
homeless youths
identify as LGBT
In one study, LGB youth were 4 to 13
times more likely to be homeless than
their heterosexual peers
61.
Intimate Partner Violence (IPV)
A nationally representative sample found that almost
one-quarter of adolescents in same-sex relationships
reported some type of partner violence
Transgender people experience higher rates of IPV
than both heterosexual and other LGBQ communities
Threat of “outing” a partner is a unique form of
psychological abuse
62.
Safety and Victimization at School
2011 Findings from a Nationwide School Survey
In the past year,
LGBT Youth reported:
Increased risk of
bullying and
harassment due to
sexual orientation
82% report verbal
harassment
(threatened)
55% report electronic
harassment
“cyberbullying”
38% report physical
harassment
(pushed/shoved)
63.
Negative Effects of a
Hostile School Environment
Poorer Psychological Well-Being
(Depression and low self-esteem)
Lowered Educational Aspirations and
Academic Achievement
Absenteeism
(Missing class/school days)
64. Impact of homophobia/
transphobia
• Trauma/violence
• Discrimination
• Rejection
• Lack of civil rights
Internalizing effects of homophobia/
transphobia
Decreased
access to
competent
health services
*
*
* *
Poor health outcomes
• No screening
• Low compliance
• Present late in disease
• Unsafe sex
Poor psychological outcomes
* Where culturally
competent medical and
mental health care can
be a mitigating factor
• Stigma
• Shame
• Isolation
• Stress
• Depression
• Anxiety
• Low self-
esteem
• (Resiliency)
• (Better
coping
strategies)
• Suicide
• Unsafe sex
• Substance use
• Eating disorders
65.
Mitigating Factors
Effects of discrimination are mediated by available
social support, development stage of youth, and
other personal characteristics
Family/ friend support
• Youth who experience severe family rejection are 8 times
more likely to attempt suicide
Support in schools
• Presence of Gay-Straight Alliances, curriculum inclusive
of LGBT issues, and supportive staff in schools linked to
healthier outcomes
66. Resilience of LGBTQ Youth
Many LGBTQ teens lead
healthy, productive lives
Resilient adaptations to
social biases and
mistreatment
Develop and possess
remarkable strength and
self-determination
67.
Hope Remains
Three-quarters (77%) of LGBT youth say they know
things will get better
Young people are resilient
“This is me, this is how I was born, and I’m happy
with it”
68.
Case: Sophia Continued
On a follow up visit for tiredness,
Sophia seems distracted
When you ask her what is wrong,
she says she is worried that she
might be pregnant
69.
Bisexual and Lesbian Women: Greater
Risk for Negative Health Outcomes
Data source (2006-2010 NSFG): Self-identified
bisexual, lesbian, and heterosexual women aged 15-
20
Results for bisexual/lesbian women:
Younger age at heterosexual debut
More male and female sexual partners
More likely to report forced sex by male partner
Greatest use of EC and highest frequency of abortion
among bisexual young women
70.
Increased Risk
• Trichomonas
• HPV
• Bacterial vaginosis
• HIV
WSW STI Risk
Nationwide, 6,935 self-identified lesbians
17.2% reported past history STI
71.
CDC 2010 Guidelines for WSW
Routine age appropriate screening guidelines
Pap
Chlamydia screening
WSW may be at risk, benefit from screening
Trichomonas
Bacterial Vaginosis
HSV
HPV
HIV
72.
Contraceptive Use
Young women who identified themselves as “unsure”
of their sexual orientation are:
Almost twice as likely to report no contraceptive use at
last sex
73.
Pregnancy Risk
When
compared to
heterosexual
youth, lesbians
and bisexual
females:
Are about as likely to have
had intercourse
Experience twice the rate
of pregnancy (12% vs. 6%)
Are more likely to have had
two or more pregnancies
(23.5% vs. 9.8%)
19 times less likely to
perceive at themselves at
risk for STI
75.
Sophia: Case Wrap Up
Ask all adolescent patients about sexual orientation
Assess patients’ feelings about disclosures
Understand that behavior does not match identity—
discuss contraception and condom use
76.
Case: Martin
Michael is 16 years old at office for sports physical
He reports exercising, not using drugs, religion as
important aspects of his role as a student and athlete
His mom confirms he is an exemplary student and
star athlete
When you ask him about
having a girlfriend, he says he
has never.
When you follow up with asking
him who he is attracted to and
has he ever had a crush or
romantic relationship, he
reports: “I have sex with guys
but I am not gay.”
77.
Skill: Avoiding Assumptions
Many male youth do not identify as
gay but have same-sex partners
Orientation/attraction do not always =
behavior
81% of females with same-sex attraction also report having
sexual experiences with males
79.
Sexual Behavior Questions
Framing the question
Developmentally appropriate
To counsel and advise not judge!
There are many ways of being sexual or intimate with
another person: kissing, hugging, touching, having
oral sex, anal sex, or vaginal sex.
Have you ever had any of these
experiences?
Which ones?
With males, females, or both?
81.
Female Sexual Activity, Same-Sex
Partners
2006–2008 National Survey of Family Growth
10.30% 11.90%
5.40% 9.30%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
15-17 years 18-19 years
Anysexual experience
**
AnyOral Sex
**Includes oral sex and answering “yes” more generally to having had any sexual
experience with another female
82.
Male Sexual Activity, Same-Sex
Partners
1.70%
3.90%
1.30%
3.70%
1.10% 1.50%
0%
5%
10%
15%
20%
25%
30%
15-17 years 18-19 years
Any Oral or Anal Sex Any Oral Sex Any Anal Sex
2006-2008 National Survey of Family Growth
83.
Case: Martin
He reports having sex with a
“friend”
His friend is at a local college
After discussing the tests that you
will run, you ask about condom
use
He reports that he uses condoms
most of the time
84.
Discuss Healthy Relationships
What does a healthy relationship look like to YOU?
Who makes the decisions
about when to have sex?
Do you use condoms or
contraceptives?
Is your partner
trustworthy
& caring?
Are you
ready for
sex?
Contraception?
STI
prevention
?
85.
STI Prevention Counseling
Cover it up!!
Condom use
With insertive or receptive sex
Rectum, vagina, mouth
Sex toys
Do not share insertive sex toys without a condom
Wash sex toys after each use
Dental dam use with oral sex
86.
YMSM Condom Use
27%-48% engaged in unprotected anal sex <6
months before
87.
Counseling About Condom Use
Explore why or why not
Withhold judgment
Respect concerns
Listen to concerns of discomfort or sizing issues
Offer a wide range of condoms including larger sizes
and different colors
88.
CDC 2010 Guidelines for MSM
Routine laboratory screening for common STDs is
indicated for all sexually active MSM. The following
screening tests should be performed at least annually
for sexually active MSM:
HIV
Syphilis
Test at anatomic sites of exposure:
Urethral test with N. gonorrhoeae and C. trachomatis
Rectal infection with N. gonorrhoeae and C.
trachomatis
Pharyngeal infection with N. gonorrhoeae
89.
Rectal/Pharyngeal
Chlamydia and Gonorrhea
• Nucleic acid based testing (NAAT) is most sensitive
at detecting both Chlamydia and Gonorrhea
• CDC recommends as first-line for testing urine,
cervical, and urethral specimens
• Not FDA approved for rectal or oropharyngeal
swabs but still recommended by CDC as first-line
• individual labs have established performance
specifications, allowing results to be used for
clinical management
GC culture on chocolate agar plate is an
acceptable alternative to NAAT; NAAT is
more sensitive but culture allows for
antibiotic susceptibility testing
90.
Additional Considerations for MSM
Consider screen or test for
HSV type-specific serologies
Hep A, B, C surface antibodies
Anal trichomonas
Don’t forget preventive vaccinations!
Hepatitis A & B
HPV Emerging questions?
•HPV oral
•Anal pap cancer
91.
Cases: Wrap-Up
Ask all adolescent patients about gender identity,
sexual orientation, specific sexual behaviors
Assess patients’ feelings, safety, support when
counseling about disclosures
Understand that biology, identity, and expression
may be diverse
Offer LGBTQ teens the same private/confidential
care for STI & pregnancy prevention, healthy
relationship support
92.
Review of Objectives
Can you:
Identify three risk factors faced by LGBTQ youth
Discuss the ways that homophobia contributes to
LGBTQ health outcomes
List three elements of LGBTQ competent health care
delivery
Describe resources for LGBTQ youth
93.
Specialized Health Services
Hasbro Children’s Hospital (Providence)—
www.hasbrochildrenshospital.org
Children’s Hospital Los Angeles—http://www.chla.org
BC Childrens Hospital (Vancouver)—www.bchildrens.ca
Howard Brown Health Center (Chicago)—
www.howardbrown.org/hb_services.asp?id=37
Mazzoni Center (Philadelphia)—mazzonicenter.org
Whitman Walker Clinic (Washington, DC)—www.wwc.org
Fenway Institute (Boston)—www.fenwayhealth.org
Callen-Lorde Community Health Center (New York)—
www.callen-lorde.org
94.
Family Support Resources
www.pflag.org—Parents and Friends of Lesbians and
Gays
familyproject.sfsu.edu—Family Acceptance Project
95.
Provider Resources and Organizational
Partners
www.advocatesforyouth.org—Advocates for Youth
www.aap.org—American Academy of Pediatricians
www.aclu.org/reproductive-freedom American Civil Liberties
Union Reproductive Freedom Project
www.acog.org—American College of Obstetricians and
Gynecologists
www.arhp.org—Association of Reproductive Health
Professionals
www.cahl.org—Center for Adolescent Health and the Law
www.glma.org Gay and Lesbian Medical Association
96.
www.guttmacher.org—Guttmacher Institute
janefondacenter.emory.edu Jane Fonda Center at Emory
University
www.msm.edu Morehouse School of Medicine
www.prochoiceny.org/projects-campaigns/torch.shtml NARAL
Pro-Choice New York Teen Outreach Reproductive Challenge
(TORCH)
www.naspag.org North American Society of Pediatric and
Adolescent Gynecology
www.prh.org—Physicians for Reproductive Health
Provider Resources and Organizational
Partners
97.
Provider Resources and Organizational
Partners
www.siecus.org—Sexuality Information and Education Council
of the United States
www.adolescenthealth.org—Society for Adolescent Health and
Medicine
www.plannedparenthood.org Planned Parenthood Federation of
America
www.reproductiveaccess.org Reproductive Health Access
Project
www.spence-chapin.org Spence-Chapin Adoption Services