Gayathri Chelvakumar, MD

It has been known for decades that sex and gender cannot be determined solely by birth anatomy and chromosomes.¹ Over the past decade, the medical community has been able to better understand the biologic underpinnings of gender identity, and we are gaining a better appreciation for the diversity of gender identities and gender expressions that exist.

Gender expression can be defined as the manner in which an individual chooses to present their gender to others through physical appearance and behaviors, such as style of hair or dress, voice or movement.² Gender nonconformity (GNC) is when an individual’s gender expression does not fully conform with societal expectations often based on an individual’s sex assigned at birth. It is important to note that gender expression is independent of gender identity and may or may not align with gender identity. For example, a person whose sex assigned at birth is female may adopt hairstyles and clothing that are considered more masculine and enjoy activities that are typically associated with masculinity (for example, sports) yet identify as female. The majority of research to date focuses most on transgender individuals, broadly defined as those whose gender identity does not fully align with the sex assigned at birth.^3,4 As our understanding of gender expression and GNC expands, more research is emerging on the prevalence of gender nonconformity in youth and potential associations with various health outcomes.

Stigma, discrimination, and harassment are known to have documented effects on health. GNC youth have been shown to experience discrimination and harassment at rates higher than their gender conforming peers.^5,6 A recent study by Lowry et al. sought to examine the association between GNC and indicators of mental distress and substance use in adolescents.⁷ The authors analyzed a subset of cross-sectional data from more than 6,000 youth who had participated in the Youth Risk Behavior Surveillance–United States, 2015 (YRBS) in three large urban school districts (two in California and one in Florida). In addition to the standard YRBS questions, students at these three school districts were asked about their gender expression using the following question: “A person’s appearance style, dress, or the way they walk or talk may affect how people describe them. How do you think people at your school would describe you?” Based on responses, youth were categorized on a 7-point GNC scale with 1 being most gender conforming (a very feminine female student or very masculine male student) to 7 being most GNC (a very masculine female student or a very feminine male student). The study sample was ethnically diverse with 16% of students identifying as white non-Hispanic, 19% identifying as black non-Hispanic, and 55% identifying as Hispanic of any race.

In the study population, approximately one in five students reported either moderate (students who described themselves as equally feminine and masculine) or high (female students who described themselves as very/mostly/somewhat masculine or male students who described themselves as very/mostly/somewhat feminine) levels of GNC. Among female students, moderate GNC was significantly associated with feeling sad and hopeless, seriously considering attempting suicide, and making a suicide plan. However, in female students substance use was not associated with GNC. Among male students, suicidal thoughts, plans, and attempts all demonstrated a linear increase with GNC, with the greatest prevalence occurring in male students expressing high levels of GNC. Prevalence of substance use, specifically nonmedical use of prescription drugs, cocaine use, methamphetamine use, heroin use, and intravenous drug also was associated with high GNC in male students. Study authors hypothesize that these differences occur because GNC male youth experience more overt harassment, compared with GNC female youth, but further study is needed.

Our understanding of the diversity of gender expressions present in youth populations continues to evolve. Findings from this study add to a growing body of evidence demonstrating a relatively high prevalence of GNC in youth populations, and potential health disparities these youth may face. This study underscores the need for continued study in this area. Family support and acceptance have been demonstrated to be strong protective factors for transgender-, lesbian-, and gay-identified youth. Studies identifying protective factors for GNC youth are needed.⁴

As health care providers, we need to continue to ask patients and families about gender identity and be aware of gender expression. When youth present as GNC, we should recognize that they may be at increased risk and, in addition to assessing overall mental health and risk for substance use, also assess for degree of social/familial support and potential stressors.4 We also should continue to advocate for support systems within schools sensitive to the needs of GNC students, as these may be a potential avenue to improve overall mental health for students. It is important to continue to expand our understanding of the diverse gender identities and expressions of the youth we serve. This hopefully will allow us to identify not only potential risk factors and health disparities, but also protective factors that can help better inform the development of effective interventions so all youth can reach their full potential.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. Email her at pdnews@mdedge.com.

References

1. “WPATH (World Professional Association of Transgender Health) Board Responds to Federal Effort to Redefine Gender,” press release, Oct. 23, 2018.

2. “LGBTQ+ Definitions” at Trans Student Educational Resources.3. J Sex Res. 2013;50(3-4):299-317.

4. JAMA Pediatr. 2018 Nov 1;172(11):1010-1.

5. Psychol Sex Orientat Gend Divers. 2016 Dec;3(4):489-98.

6. J Adolesc Health. 2016; 58(2)(supple):S1-2.

7. JAMA Pediatr. 2018 Nov;172(11):1020-8.

It has been known for decades that sex and gender cannot be determined solely by birth anatomy and chromosomes.¹ Over the past decade, the medical community has been able to better understand the biologic underpinnings of gender identity, and we are gaining a better appreciation for the diversity of gender identities and gender expressions that exist.

Gender expression can be defined as the manner in which an individual chooses to present their gender to others through physical appearance and behaviors, such as style of hair or dress, voice or movement.² Gender nonconformity (GNC) is when an individual’s gender expression does not fully conform with societal expectations often based on an individual’s sex assigned at birth. It is important to note that gender expression is independent of gender identity and may or may not align with gender identity. For example, a person whose sex assigned at birth is female may adopt hairstyles and clothing that are considered more masculine and enjoy activities that are typically associated with masculinity (for example, sports) yet identify as female. The majority of research to date focuses most on transgender individuals, broadly defined as those whose gender identity does not fully align with the sex assigned at birth.^3,4 As our understanding of gender expression and GNC expands, more research is emerging on the prevalence of gender nonconformity in youth and potential associations with various health outcomes.

Stigma, discrimination, and harassment are known to have documented effects on health. GNC youth have been shown to experience discrimination and harassment at rates higher than their gender conforming peers.^5,6 A recent study by Lowry et al. sought to examine the association between GNC and indicators of mental distress and substance use in adolescents.⁷ The authors analyzed a subset of cross-sectional data from more than 6,000 youth who had participated in the Youth Risk Behavior Surveillance–United States, 2015 (YRBS) in three large urban school districts (two in California and one in Florida). In addition to the standard YRBS questions, students at these three school districts were asked about their gender expression using the following question: “A person’s appearance style, dress, or the way they walk or talk may affect how people describe them. How do you think people at your school would describe you?” Based on responses, youth were categorized on a 7-point GNC scale with 1 being most gender conforming (a very feminine female student or very masculine male student) to 7 being most GNC (a very masculine female student or a very feminine male student). The study sample was ethnically diverse with 16% of students identifying as white non-Hispanic, 19% identifying as black non-Hispanic, and 55% identifying as Hispanic of any race.

In the study population, approximately one in five students reported either moderate (students who described themselves as equally feminine and masculine) or high (female students who described themselves as very/mostly/somewhat masculine or male students who described themselves as very/mostly/somewhat feminine) levels of GNC. Among female students, moderate GNC was significantly associated with feeling sad and hopeless, seriously considering attempting suicide, and making a suicide plan. However, in female students substance use was not associated with GNC. Among male students, suicidal thoughts, plans, and attempts all demonstrated a linear increase with GNC, with the greatest prevalence occurring in male students expressing high levels of GNC. Prevalence of substance use, specifically nonmedical use of prescription drugs, cocaine use, methamphetamine use, heroin use, and intravenous drug also was associated with high GNC in male students. Study authors hypothesize that these differences occur because GNC male youth experience more overt harassment, compared with GNC female youth, but further study is needed.

Our understanding of the diversity of gender expressions present in youth populations continues to evolve. Findings from this study add to a growing body of evidence demonstrating a relatively high prevalence of GNC in youth populations, and potential health disparities these youth may face. This study underscores the need for continued study in this area. Family support and acceptance have been demonstrated to be strong protective factors for transgender-, lesbian-, and gay-identified youth. Studies identifying protective factors for GNC youth are needed.⁴

As health care providers, we need to continue to ask patients and families about gender identity and be aware of gender expression. When youth present as GNC, we should recognize that they may be at increased risk and, in addition to assessing overall mental health and risk for substance use, also assess for degree of social/familial support and potential stressors.4 We also should continue to advocate for support systems within schools sensitive to the needs of GNC students, as these may be a potential avenue to improve overall mental health for students. It is important to continue to expand our understanding of the diverse gender identities and expressions of the youth we serve. This hopefully will allow us to identify not only potential risk factors and health disparities, but also protective factors that can help better inform the development of effective interventions so all youth can reach their full potential.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. Email her at pdnews@mdedge.com.

References

1. “WPATH (World Professional Association of Transgender Health) Board Responds to Federal Effort to Redefine Gender,” press release, Oct. 23, 2018.

2. “LGBTQ+ Definitions” at Trans Student Educational Resources.3. J Sex Res. 2013;50(3-4):299-317.

4. JAMA Pediatr. 2018 Nov 1;172(11):1010-1.

5. Psychol Sex Orientat Gend Divers. 2016 Dec;3(4):489-98.

6. J Adolesc Health. 2016; 58(2)(supple):S1-2.

7. JAMA Pediatr. 2018 Nov;172(11):1020-8.

It has been known for decades that sex and gender cannot be determined solely by birth anatomy and chromosomes.¹ Over the past decade, the medical community has been able to better understand the biologic underpinnings of gender identity, and we are gaining a better appreciation for the diversity of gender identities and gender expressions that exist.

Gender expression can be defined as the manner in which an individual chooses to present their gender to others through physical appearance and behaviors, such as style of hair or dress, voice or movement.² Gender nonconformity (GNC) is when an individual’s gender expression does not fully conform with societal expectations often based on an individual’s sex assigned at birth. It is important to note that gender expression is independent of gender identity and may or may not align with gender identity. For example, a person whose sex assigned at birth is female may adopt hairstyles and clothing that are considered more masculine and enjoy activities that are typically associated with masculinity (for example, sports) yet identify as female. The majority of research to date focuses most on transgender individuals, broadly defined as those whose gender identity does not fully align with the sex assigned at birth.^3,4 As our understanding of gender expression and GNC expands, more research is emerging on the prevalence of gender nonconformity in youth and potential associations with various health outcomes.

Stigma, discrimination, and harassment are known to have documented effects on health. GNC youth have been shown to experience discrimination and harassment at rates higher than their gender conforming peers.^5,6 A recent study by Lowry et al. sought to examine the association between GNC and indicators of mental distress and substance use in adolescents.⁷ The authors analyzed a subset of cross-sectional data from more than 6,000 youth who had participated in the Youth Risk Behavior Surveillance–United States, 2015 (YRBS) in three large urban school districts (two in California and one in Florida). In addition to the standard YRBS questions, students at these three school districts were asked about their gender expression using the following question: “A person’s appearance style, dress, or the way they walk or talk may affect how people describe them. How do you think people at your school would describe you?” Based on responses, youth were categorized on a 7-point GNC scale with 1 being most gender conforming (a very feminine female student or very masculine male student) to 7 being most GNC (a very masculine female student or a very feminine male student). The study sample was ethnically diverse with 16% of students identifying as white non-Hispanic, 19% identifying as black non-Hispanic, and 55% identifying as Hispanic of any race.

In the study population, approximately one in five students reported either moderate (students who described themselves as equally feminine and masculine) or high (female students who described themselves as very/mostly/somewhat masculine or male students who described themselves as very/mostly/somewhat feminine) levels of GNC. Among female students, moderate GNC was significantly associated with feeling sad and hopeless, seriously considering attempting suicide, and making a suicide plan. However, in female students substance use was not associated with GNC. Among male students, suicidal thoughts, plans, and attempts all demonstrated a linear increase with GNC, with the greatest prevalence occurring in male students expressing high levels of GNC. Prevalence of substance use, specifically nonmedical use of prescription drugs, cocaine use, methamphetamine use, heroin use, and intravenous drug also was associated with high GNC in male students. Study authors hypothesize that these differences occur because GNC male youth experience more overt harassment, compared with GNC female youth, but further study is needed.

Our understanding of the diversity of gender expressions present in youth populations continues to evolve. Findings from this study add to a growing body of evidence demonstrating a relatively high prevalence of GNC in youth populations, and potential health disparities these youth may face. This study underscores the need for continued study in this area. Family support and acceptance have been demonstrated to be strong protective factors for transgender-, lesbian-, and gay-identified youth. Studies identifying protective factors for GNC youth are needed.⁴

As health care providers, we need to continue to ask patients and families about gender identity and be aware of gender expression. When youth present as GNC, we should recognize that they may be at increased risk and, in addition to assessing overall mental health and risk for substance use, also assess for degree of social/familial support and potential stressors.4 We also should continue to advocate for support systems within schools sensitive to the needs of GNC students, as these may be a potential avenue to improve overall mental health for students. It is important to continue to expand our understanding of the diverse gender identities and expressions of the youth we serve. This hopefully will allow us to identify not only potential risk factors and health disparities, but also protective factors that can help better inform the development of effective interventions so all youth can reach their full potential.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. Email her at pdnews@mdedge.com.

References

1. “WPATH (World Professional Association of Transgender Health) Board Responds to Federal Effort to Redefine Gender,” press release, Oct. 23, 2018.

2. “LGBTQ+ Definitions” at Trans Student Educational Resources.3. J Sex Res. 2013;50(3-4):299-317.

4. JAMA Pediatr. 2018 Nov 1;172(11):1010-1.

5. Psychol Sex Orientat Gend Divers. 2016 Dec;3(4):489-98.

6. J Adolesc Health. 2016; 58(2)(supple):S1-2.

7. JAMA Pediatr. 2018 Nov;172(11):1020-8.

June 28, 1969, is the day that many consider to be the origin of the modern LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning) movement.¹ At that time, it was not uncommon for police officers to conduct raids on bars frequented by LGBTQ patrons, but this night was different. This night the patrons of the Stonewall Inn fought back. The subsequent violent clashes fueled the national organization of groups concentrated on the goal of advocating for LGBTQ rights. On June 28th, 1970, protests to commemorate the events at Stonewall occurred; many refer to these as the first Pride events. Since then the month of June has been seen as the unofficial Pride month for the LGBTQ community. These events began as demonstrations for equal rights and protections for LGBTQ individuals, but over time, events have grown also to become a celebration of queer lives and sexuality.²

Josve05a/Getty Images

Ways to get involved

Find out about local Pride events in your community and consider attending or volunteering. One of the contributing factors to LGBTQ health disparities is limited access to competent care. Many LGBTQ youth and adults have reported experiences of discrimination in the health care setting.^3,4 When we, as health care providers, are visible at Pride events, we can have important effects on our local communities by showing them that we recognize and affirm LGBTQ identities.

Consider asking your organization or institution to provide support at local Pride events, post messages of support during Pride month, or host educational sessions about the care of LGBTQ youth.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

Resources

Human Rights Campaign/Pride: You can learn more about the history of Pride and events in your state and community at www.hrc.org/pride.

How to contact your elected officials: You can find contact information for your local, state, and federal government representatives at www.usa.gov/elected-officials.

National LGBT Health Education Center: You can find educational resources to help optimize care of LGBT patients at www.lgbthealtheducation.org/.

U.S. Transgender Survey: You can read the report from a survey of almost 28,000 transgender respondents in the U.S. Specific information is available about experiences with health care; state level reports also available at www.ustranssurvey.org/reports/.
 

References

1. GLAAD Pride Month Resource Kit for Jounalists: www.glaad.org/publications/pridekit

2. Human Rights Campaign: History of LGBT Pride. www.hrc.org/blog/the-history-of-lgbt-pride-from-1970-to-now

3. The Report of the 2015 U.S. Transgender Survey (Washington, DC: National Center for Transgender Equality, 2016).

4. Healthy People 2020: Lesbian, Gay, Bisexual and Transgender Health.

June 28, 1969, is the day that many consider to be the origin of the modern LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning) movement.¹ At that time, it was not uncommon for police officers to conduct raids on bars frequented by LGBTQ patrons, but this night was different. This night the patrons of the Stonewall Inn fought back. The subsequent violent clashes fueled the national organization of groups concentrated on the goal of advocating for LGBTQ rights. On June 28th, 1970, protests to commemorate the events at Stonewall occurred; many refer to these as the first Pride events. Since then the month of June has been seen as the unofficial Pride month for the LGBTQ community. These events began as demonstrations for equal rights and protections for LGBTQ individuals, but over time, events have grown also to become a celebration of queer lives and sexuality.²

Josve05a/Getty Images

Ways to get involved

Find out about local Pride events in your community and consider attending or volunteering. One of the contributing factors to LGBTQ health disparities is limited access to competent care. Many LGBTQ youth and adults have reported experiences of discrimination in the health care setting.^3,4 When we, as health care providers, are visible at Pride events, we can have important effects on our local communities by showing them that we recognize and affirm LGBTQ identities.

Consider asking your organization or institution to provide support at local Pride events, post messages of support during Pride month, or host educational sessions about the care of LGBTQ youth.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

Resources

Human Rights Campaign/Pride: You can learn more about the history of Pride and events in your state and community at www.hrc.org/pride.

How to contact your elected officials: You can find contact information for your local, state, and federal government representatives at www.usa.gov/elected-officials.

National LGBT Health Education Center: You can find educational resources to help optimize care of LGBT patients at www.lgbthealtheducation.org/.

U.S. Transgender Survey: You can read the report from a survey of almost 28,000 transgender respondents in the U.S. Specific information is available about experiences with health care; state level reports also available at www.ustranssurvey.org/reports/.
 

References

1. GLAAD Pride Month Resource Kit for Jounalists: www.glaad.org/publications/pridekit

2. Human Rights Campaign: History of LGBT Pride. www.hrc.org/blog/the-history-of-lgbt-pride-from-1970-to-now

3. The Report of the 2015 U.S. Transgender Survey (Washington, DC: National Center for Transgender Equality, 2016).

4. Healthy People 2020: Lesbian, Gay, Bisexual and Transgender Health.

June 28, 1969, is the day that many consider to be the origin of the modern LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning) movement.¹ At that time, it was not uncommon for police officers to conduct raids on bars frequented by LGBTQ patrons, but this night was different. This night the patrons of the Stonewall Inn fought back. The subsequent violent clashes fueled the national organization of groups concentrated on the goal of advocating for LGBTQ rights. On June 28th, 1970, protests to commemorate the events at Stonewall occurred; many refer to these as the first Pride events. Since then the month of June has been seen as the unofficial Pride month for the LGBTQ community. These events began as demonstrations for equal rights and protections for LGBTQ individuals, but over time, events have grown also to become a celebration of queer lives and sexuality.²

Josve05a/Getty Images

Ways to get involved

Find out about local Pride events in your community and consider attending or volunteering. One of the contributing factors to LGBTQ health disparities is limited access to competent care. Many LGBTQ youth and adults have reported experiences of discrimination in the health care setting.^3,4 When we, as health care providers, are visible at Pride events, we can have important effects on our local communities by showing them that we recognize and affirm LGBTQ identities.

Consider asking your organization or institution to provide support at local Pride events, post messages of support during Pride month, or host educational sessions about the care of LGBTQ youth.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

Resources

Human Rights Campaign/Pride: You can learn more about the history of Pride and events in your state and community at www.hrc.org/pride.

How to contact your elected officials: You can find contact information for your local, state, and federal government representatives at www.usa.gov/elected-officials.

National LGBT Health Education Center: You can find educational resources to help optimize care of LGBT patients at www.lgbthealtheducation.org/.

U.S. Transgender Survey: You can read the report from a survey of almost 28,000 transgender respondents in the U.S. Specific information is available about experiences with health care; state level reports also available at www.ustranssurvey.org/reports/.
 

References

1. GLAAD Pride Month Resource Kit for Jounalists: www.glaad.org/publications/pridekit

2. Human Rights Campaign: History of LGBT Pride. www.hrc.org/blog/the-history-of-lgbt-pride-from-1970-to-now

3. The Report of the 2015 U.S. Transgender Survey (Washington, DC: National Center for Transgender Equality, 2016).

4. Healthy People 2020: Lesbian, Gay, Bisexual and Transgender Health.

As we providers begin to gain a better understanding of the complexities of gender identity and expression, studies examining the health of transgender and gender-nonconforming (TGNC) youth are emerging. Multiple studies have demonstrated the mental health disparities that TGNC youth face, but more studies examining other health risks and disparities are needed.

Prevalence of TGNC students higher than expected

The 2.7% prevalence of TGNC youth in this sample is higher than previously reported. Previous studies looking at prevalence rates of TGNC youth often dichotomized gender identities into binary (masculine or feminine) groups and were not inclusive of nonbinary and questioning identities. This may have led to underestimation of the size of this population.^2,3 This study assessed for TGNC identities by asking, “Do you consider yourself transgender, genderqueer, gender fluid, or unsure about your gender identity?” Given the prevalence of TGNC identities in this sample, it is likely that TGNC youth will be encountered in general pediatric practice. As such, it is important that we as providers continue to build our competency in working with this population.
 

Statistically significant differences in health status were identified

Almost two-thirds (62%) of TGNC youth identified their health as poor, fair, or good as opposed to very good or excellent, compared with one-third (33.1%) of cisgender youth. Over half (52%) of TGNC youth reported staying home from school because of illness at least once in the past month, compared with 43% of cisgender youth. About 60% of TGNC youth reported a preventive medical check-up in the past year, compared with 65% of cisgender youth. In terms of long-term health problems, TGNC youth reported higher rates of long-term physical (25% vs. 15%) and mental health (59% vs. 17%) problems than did their cisgender peers.

Role of perceived gender expression

A unique aspect of this study was that it sought to examine the effect of perceived gender expression (the way others interpret a person’s gender presentation; their appearance, style, dress, or the way they walk or talk) on health status and care utilization. Categories of perceived gender expression included very or mostly feminine, somewhat feminine, equally feminine and masculine, somewhat masculine, or very or mostly masculine. The prevalence of TGNC adolescents with an equally feminine and masculine gender expression was highest for both those assigned male (29%) and assigned female (41%) at birth, compared with other perceived gender presentations.

TGNC youth who were perceived to have a gender expression that was incongruent with the sex assigned at birth were at higher risk of reporting poor health status. For example, in TGNC participants who were assigned male at birth, those perceived as equally feminine and masculine (49%) or somewhat masculine (58%) were significantly more likely to report having poorer general health than those with a very masculine perceived gender expression (32%).
 

Suggestions for providers

The authors of the study and the accompanying commentary by Daniel Shumer, MD, MPH, suggest that there are things we as health care providers can do to address these barriers.

• Recognize that health disparities exist in this population. Individuals perceived as gender nonconforming may be vulnerable to discrimination and have difficulty accessing and receiving heath care, compared with their cisgender peers.
• Screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.
• Continue to promote access to gender affirming care. Data suggest that children who receive gender affirming care achieve mental health status similar to that of their cisgender peers.^3,4,5
• Continue to develop an understanding of how youth understand and express gender.
• Nonbinary youth face unique barriers when accessing health affirming services because of fears that their gender identity may be misunderstood. These barriers lead to delays in seeking health care services, which may lead to poorer outcomes. As providers, educating ourselves about these diverse identities and being respectful of all patients’ identities can help reduce these barriers.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

References

1. Pediatrics. 2018 Feb 5. doi: 10.1542/peds.2017-1683.

2. J Adolesc Health. 2017 Oct;61(4):521-6.

3. Pediatrics. 2018. doi: 10.1542/peds.2017-4079.

4. Pediatrics. 2014 Oct;134(4):696-704.

5. Pediatrics. 2016 Mar;137(3):e20153223.

As we providers begin to gain a better understanding of the complexities of gender identity and expression, studies examining the health of transgender and gender-nonconforming (TGNC) youth are emerging. Multiple studies have demonstrated the mental health disparities that TGNC youth face, but more studies examining other health risks and disparities are needed.

Prevalence of TGNC students higher than expected

The 2.7% prevalence of TGNC youth in this sample is higher than previously reported. Previous studies looking at prevalence rates of TGNC youth often dichotomized gender identities into binary (masculine or feminine) groups and were not inclusive of nonbinary and questioning identities. This may have led to underestimation of the size of this population.^2,3 This study assessed for TGNC identities by asking, “Do you consider yourself transgender, genderqueer, gender fluid, or unsure about your gender identity?” Given the prevalence of TGNC identities in this sample, it is likely that TGNC youth will be encountered in general pediatric practice. As such, it is important that we as providers continue to build our competency in working with this population.
 

Statistically significant differences in health status were identified

Almost two-thirds (62%) of TGNC youth identified their health as poor, fair, or good as opposed to very good or excellent, compared with one-third (33.1%) of cisgender youth. Over half (52%) of TGNC youth reported staying home from school because of illness at least once in the past month, compared with 43% of cisgender youth. About 60% of TGNC youth reported a preventive medical check-up in the past year, compared with 65% of cisgender youth. In terms of long-term health problems, TGNC youth reported higher rates of long-term physical (25% vs. 15%) and mental health (59% vs. 17%) problems than did their cisgender peers.

Role of perceived gender expression

A unique aspect of this study was that it sought to examine the effect of perceived gender expression (the way others interpret a person’s gender presentation; their appearance, style, dress, or the way they walk or talk) on health status and care utilization. Categories of perceived gender expression included very or mostly feminine, somewhat feminine, equally feminine and masculine, somewhat masculine, or very or mostly masculine. The prevalence of TGNC adolescents with an equally feminine and masculine gender expression was highest for both those assigned male (29%) and assigned female (41%) at birth, compared with other perceived gender presentations.

TGNC youth who were perceived to have a gender expression that was incongruent with the sex assigned at birth were at higher risk of reporting poor health status. For example, in TGNC participants who were assigned male at birth, those perceived as equally feminine and masculine (49%) or somewhat masculine (58%) were significantly more likely to report having poorer general health than those with a very masculine perceived gender expression (32%).
 

Suggestions for providers

The authors of the study and the accompanying commentary by Daniel Shumer, MD, MPH, suggest that there are things we as health care providers can do to address these barriers.

• Recognize that health disparities exist in this population. Individuals perceived as gender nonconforming may be vulnerable to discrimination and have difficulty accessing and receiving heath care, compared with their cisgender peers.
• Screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.
• Continue to promote access to gender affirming care. Data suggest that children who receive gender affirming care achieve mental health status similar to that of their cisgender peers.^3,4,5
• Continue to develop an understanding of how youth understand and express gender.
• Nonbinary youth face unique barriers when accessing health affirming services because of fears that their gender identity may be misunderstood. These barriers lead to delays in seeking health care services, which may lead to poorer outcomes. As providers, educating ourselves about these diverse identities and being respectful of all patients’ identities can help reduce these barriers.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

References

1. Pediatrics. 2018 Feb 5. doi: 10.1542/peds.2017-1683.

2. J Adolesc Health. 2017 Oct;61(4):521-6.

3. Pediatrics. 2018. doi: 10.1542/peds.2017-4079.

4. Pediatrics. 2014 Oct;134(4):696-704.

5. Pediatrics. 2016 Mar;137(3):e20153223.

As we providers begin to gain a better understanding of the complexities of gender identity and expression, studies examining the health of transgender and gender-nonconforming (TGNC) youth are emerging. Multiple studies have demonstrated the mental health disparities that TGNC youth face, but more studies examining other health risks and disparities are needed.

Prevalence of TGNC students higher than expected

The 2.7% prevalence of TGNC youth in this sample is higher than previously reported. Previous studies looking at prevalence rates of TGNC youth often dichotomized gender identities into binary (masculine or feminine) groups and were not inclusive of nonbinary and questioning identities. This may have led to underestimation of the size of this population.^2,3 This study assessed for TGNC identities by asking, “Do you consider yourself transgender, genderqueer, gender fluid, or unsure about your gender identity?” Given the prevalence of TGNC identities in this sample, it is likely that TGNC youth will be encountered in general pediatric practice. As such, it is important that we as providers continue to build our competency in working with this population.
 

Statistically significant differences in health status were identified

Almost two-thirds (62%) of TGNC youth identified their health as poor, fair, or good as opposed to very good or excellent, compared with one-third (33.1%) of cisgender youth. Over half (52%) of TGNC youth reported staying home from school because of illness at least once in the past month, compared with 43% of cisgender youth. About 60% of TGNC youth reported a preventive medical check-up in the past year, compared with 65% of cisgender youth. In terms of long-term health problems, TGNC youth reported higher rates of long-term physical (25% vs. 15%) and mental health (59% vs. 17%) problems than did their cisgender peers.

Role of perceived gender expression

A unique aspect of this study was that it sought to examine the effect of perceived gender expression (the way others interpret a person’s gender presentation; their appearance, style, dress, or the way they walk or talk) on health status and care utilization. Categories of perceived gender expression included very or mostly feminine, somewhat feminine, equally feminine and masculine, somewhat masculine, or very or mostly masculine. The prevalence of TGNC adolescents with an equally feminine and masculine gender expression was highest for both those assigned male (29%) and assigned female (41%) at birth, compared with other perceived gender presentations.

TGNC youth who were perceived to have a gender expression that was incongruent with the sex assigned at birth were at higher risk of reporting poor health status. For example, in TGNC participants who were assigned male at birth, those perceived as equally feminine and masculine (49%) or somewhat masculine (58%) were significantly more likely to report having poorer general health than those with a very masculine perceived gender expression (32%).
 

Suggestions for providers

The authors of the study and the accompanying commentary by Daniel Shumer, MD, MPH, suggest that there are things we as health care providers can do to address these barriers.

• Recognize that health disparities exist in this population. Individuals perceived as gender nonconforming may be vulnerable to discrimination and have difficulty accessing and receiving heath care, compared with their cisgender peers.
• Screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.
• Continue to promote access to gender affirming care. Data suggest that children who receive gender affirming care achieve mental health status similar to that of their cisgender peers.^3,4,5
• Continue to develop an understanding of how youth understand and express gender.
• Nonbinary youth face unique barriers when accessing health affirming services because of fears that their gender identity may be misunderstood. These barriers lead to delays in seeking health care services, which may lead to poorer outcomes. As providers, educating ourselves about these diverse identities and being respectful of all patients’ identities can help reduce these barriers.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

References

1. Pediatrics. 2018 Feb 5. doi: 10.1542/peds.2017-1683.

2. J Adolesc Health. 2017 Oct;61(4):521-6.

3. Pediatrics. 2018. doi: 10.1542/peds.2017-4079.

4. Pediatrics. 2014 Oct;134(4):696-704.

5. Pediatrics. 2016 Mar;137(3):e20153223.

For many, the holiday season is a time to celebrate, relax, and enjoy the company of family. Much of this celebrating centers on eating and food. For youth struggling with eating disorders, holidays can be a particularly challenging time. Historically, eating disorders were associated with young, straight, cisgender, white females. Data collected over the past 15 years suggest that eating disorders can affect youth of all ethnicities and genders.

Ingram Publishing/ThinkStock

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Resources

National Eating Disorders Association: www.nationaleatingdisorders.org

“Body image and eating disorders among lesbian, gay, bisexual, and transgender youth” (Pediatr Clin North Am. 2016 Dec;63[6]:1079-90.

References

1. Prev Chronic Dis. 2008 Oct;5(4):A114.

2. Arch Gen Psychiatry. 2011 Jul;68(7):714-23.

3. Pediatr Clin North Am. 2016 Dec;63(6):1079-90.

4. Curr Psychiatry Rep. 2012 Aug;14(4):391-7.

5. J Adolesc Health. 2015 Aug;57(2):144-9.

6. Am J Public Health. 2013 Feb;103(2):e16-22.

7. J Adolesc Health. 2009 Sep;45(3):238-45.
 

For many, the holiday season is a time to celebrate, relax, and enjoy the company of family. Much of this celebrating centers on eating and food. For youth struggling with eating disorders, holidays can be a particularly challenging time. Historically, eating disorders were associated with young, straight, cisgender, white females. Data collected over the past 15 years suggest that eating disorders can affect youth of all ethnicities and genders.

Ingram Publishing/ThinkStock

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Resources

National Eating Disorders Association: www.nationaleatingdisorders.org

“Body image and eating disorders among lesbian, gay, bisexual, and transgender youth” (Pediatr Clin North Am. 2016 Dec;63[6]:1079-90.

References

1. Prev Chronic Dis. 2008 Oct;5(4):A114.

2. Arch Gen Psychiatry. 2011 Jul;68(7):714-23.

3. Pediatr Clin North Am. 2016 Dec;63(6):1079-90.

4. Curr Psychiatry Rep. 2012 Aug;14(4):391-7.

5. J Adolesc Health. 2015 Aug;57(2):144-9.

6. Am J Public Health. 2013 Feb;103(2):e16-22.

7. J Adolesc Health. 2009 Sep;45(3):238-45.
 

For many, the holiday season is a time to celebrate, relax, and enjoy the company of family. Much of this celebrating centers on eating and food. For youth struggling with eating disorders, holidays can be a particularly challenging time. Historically, eating disorders were associated with young, straight, cisgender, white females. Data collected over the past 15 years suggest that eating disorders can affect youth of all ethnicities and genders.

Ingram Publishing/ThinkStock

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Resources

National Eating Disorders Association: www.nationaleatingdisorders.org

“Body image and eating disorders among lesbian, gay, bisexual, and transgender youth” (Pediatr Clin North Am. 2016 Dec;63[6]:1079-90.

References

1. Prev Chronic Dis. 2008 Oct;5(4):A114.

2. Arch Gen Psychiatry. 2011 Jul;68(7):714-23.

3. Pediatr Clin North Am. 2016 Dec;63(6):1079-90.

4. Curr Psychiatry Rep. 2012 Aug;14(4):391-7.

5. J Adolesc Health. 2015 Aug;57(2):144-9.

6. Am J Public Health. 2013 Feb;103(2):e16-22.

7. J Adolesc Health. 2009 Sep;45(3):238-45.
 

Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.¹ Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.

JackF/Thinkstock

Obtaining a sexual history

1. Clearly explain the reasons for asking sexually explicit questions.

TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.

2. Ensure confidentiality.

When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.^2,3 The Guttmacher Institute provides information about minors’ consent law in each state.⁴

3. Do not assume identity equals behavior.

Sexual and gender identity may not be predictive of sexual behaviors, and providers should not assume behaviors based on a patient’s identity.

Here are some sexual health questions you need to ask:

• Who are you attracted to? What is/are the gender(s) of your partner(s)?
• Have you ever had anal, genital, or oral sex? If yes:

Do you give, receive, or both?

When was the last time you had sex?

How many partners have you had in past 6 months?

Do you use barrier protection most of the time, some of the time, always, or never?

Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?

• Have you ever been forced/coerced into having sex?

Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.

4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit

Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.⁵ For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.⁶
 

Physical exam

Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).^1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.

Sexual health counseling

Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.⁹ In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.

Email her at pdnews@frontlinemedcom.com.

References

1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, in Center of Excellence for Transgender Health, Department of Family and Community Medicine, 2nd ed. (San Francisco: University of California, 2016).

2. Pediatrics. 2008. doi: 10.1542/peds.2008-0694.

3. J Adol Health. 2004;35:160-7.

4. An Overview of Minors’ Consent Law: State Laws and Policies. 2017, by the Guttmacher Institute.

5. Eur J Endocrinol. 2011 Aug;165(2):331-7.

6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.

7. Sex Roles. 2013 Jun 1;68(11-12):675-89.

8. J Midwifery Womens Health. 2008 Jul-Aug;53(4):331-7.

9. “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,” 2nd ed. (Philadelphia: American College of Physicians Press, 2008).

Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.¹ Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.

JackF/Thinkstock

Obtaining a sexual history

1. Clearly explain the reasons for asking sexually explicit questions.

TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.

2. Ensure confidentiality.

When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.^2,3 The Guttmacher Institute provides information about minors’ consent law in each state.⁴

3. Do not assume identity equals behavior.

Sexual and gender identity may not be predictive of sexual behaviors, and providers should not assume behaviors based on a patient’s identity.

Here are some sexual health questions you need to ask:

• Who are you attracted to? What is/are the gender(s) of your partner(s)?
• Have you ever had anal, genital, or oral sex? If yes:

Do you give, receive, or both?

When was the last time you had sex?

How many partners have you had in past 6 months?

Do you use barrier protection most of the time, some of the time, always, or never?

Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?

• Have you ever been forced/coerced into having sex?

Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.

4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit

Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.⁵ For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.⁶
 

Physical exam

Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).^1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.

Sexual health counseling

Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.⁹ In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.

Email her at pdnews@frontlinemedcom.com.

References

1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, in Center of Excellence for Transgender Health, Department of Family and Community Medicine, 2nd ed. (San Francisco: University of California, 2016).

2. Pediatrics. 2008. doi: 10.1542/peds.2008-0694.

3. J Adol Health. 2004;35:160-7.

4. An Overview of Minors’ Consent Law: State Laws and Policies. 2017, by the Guttmacher Institute.

5. Eur J Endocrinol. 2011 Aug;165(2):331-7.

6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.

7. Sex Roles. 2013 Jun 1;68(11-12):675-89.

8. J Midwifery Womens Health. 2008 Jul-Aug;53(4):331-7.

9. “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,” 2nd ed. (Philadelphia: American College of Physicians Press, 2008).

Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.¹ Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.

JackF/Thinkstock

Obtaining a sexual history

1. Clearly explain the reasons for asking sexually explicit questions.

TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.

2. Ensure confidentiality.

When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.^2,3 The Guttmacher Institute provides information about minors’ consent law in each state.⁴

3. Do not assume identity equals behavior.

Sexual and gender identity may not be predictive of sexual behaviors, and providers should not assume behaviors based on a patient’s identity.

Here are some sexual health questions you need to ask:

• Who are you attracted to? What is/are the gender(s) of your partner(s)?
• Have you ever had anal, genital, or oral sex? If yes:

Do you give, receive, or both?

When was the last time you had sex?

How many partners have you had in past 6 months?

Do you use barrier protection most of the time, some of the time, always, or never?

Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?

• Have you ever been forced/coerced into having sex?

Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.

4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit

Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.⁵ For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.⁶
 

Physical exam

Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).^1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.

Sexual health counseling

Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.⁹ In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.

Email her at pdnews@frontlinemedcom.com.

References

1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, in Center of Excellence for Transgender Health, Department of Family and Community Medicine, 2nd ed. (San Francisco: University of California, 2016).

2. Pediatrics. 2008. doi: 10.1542/peds.2008-0694.

3. J Adol Health. 2004;35:160-7.

4. An Overview of Minors’ Consent Law: State Laws and Policies. 2017, by the Guttmacher Institute.

5. Eur J Endocrinol. 2011 Aug;165(2):331-7.

6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.

7. Sex Roles. 2013 Jun 1;68(11-12):675-89.

8. J Midwifery Womens Health. 2008 Jul-Aug;53(4):331-7.

9. “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,” 2nd ed. (Philadelphia: American College of Physicians Press, 2008).

JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.

Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.¹ For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.

Design Pics/Thinkstock

• Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
• LGBT people exist in almost every faith group across the country.
• Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
• Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
• While every religion has different teachings, almost all religions advocate love and compassion.
• Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
• Remember this is your journey. You get to decide the path and the pace.
• Recognize that this may involve working for change within your community or it may mean leaving it.
• Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Spirituality resources

• LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
• Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
• LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
• HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith

References

1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).

2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)

3. Pediatrics. 2013 Jul;132(1):198-203.

4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)

5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.

JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.

Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.¹ For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.

Design Pics/Thinkstock

• Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
• LGBT people exist in almost every faith group across the country.
• Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
• Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
• While every religion has different teachings, almost all religions advocate love and compassion.
• Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
• Remember this is your journey. You get to decide the path and the pace.
• Recognize that this may involve working for change within your community or it may mean leaving it.
• Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Spirituality resources

• LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
• Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
• LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
• HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith

References

1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).

2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)

3. Pediatrics. 2013 Jul;132(1):198-203.

4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)

5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.

JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.

Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.¹ For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.

Design Pics/Thinkstock

• Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
• LGBT people exist in almost every faith group across the country.
• Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
• Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
• While every religion has different teachings, almost all religions advocate love and compassion.
• Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
• Remember this is your journey. You get to decide the path and the pace.
• Recognize that this may involve working for change within your community or it may mean leaving it.
• Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Spirituality resources

• LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
• Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
• LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
• HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith

References

1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).

2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)

3. Pediatrics. 2013 Jul;132(1):198-203.

4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)

5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.

Adolescence is a time of rapid growth and development both physically and emotionally. Some of the major tasks of adolescent development include developing a stable identity (this includes sexual and gender identity) and establishing independence from parents. This separation process from parents is often buffered by peer relationships. By the end of adolescence, those who are healthy and mature in their sexuality are able to:^1,2,3

•  Identify and live according to their own values and take responsibility for their behavior.

•  Practice effective decision-making, and develop critical-thinking skills.

•  Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.

•  Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.

•  Interact with all genders in respectful and appropriate ways.

•  Affirm their own gender identity and sexual orientation, and respect the gender identities and sexual orientations of others.

•  Appreciate their body and enjoy their sexuality throughout life, expressing sexuality in ways that are congruent with their values.

•  Express love and intimacy in appropriate ways.

•  Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.

•  Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.

Anywhere from 5% to 10% of teens identify as lesbian, gay, or bisexual (LGB).⁴ For these teens, the development of a sexual identity can add additional challenges to the development process, particularly if youth do not feel supported by family, peers, and their communities. Previous columns have addressed the role family acceptance can play in promoting the healthy development of sexual minority youth. Likewise, peer relationships also can play an important role in an adolescent’s development and health.

•  Acceptance.

•  Competence.

•  Higher levels of self-esteem and psychological well-being.

•  Strong sense of self and self-acceptance.

•  Strong ethnic identification.

•  Strong connections to family and school.

•  Caring adult role models outside the family.

•  Community involvement.

For some youth who may not be able receive acceptance from their families, peers and trusted adults may fill in this role and serve as a “chosen family.” A chosen family is commonly understood to mean a group of people who deliberately chose one another to play significant roles in each other’s lives even though they are not biologically or legally related. These relationships may be in addition to or in place of traditional family relationships. These connections can increase a youth’s sense of acceptance and connectedness and help promote resiliency.

Adolescents often may struggle on the decision of when to “come out” or disclose their sexual orientation to friends and family, and may ask their health care providers for advice. The number one consideration when making a decision about disclosure is safety. Unfortunately, some family members and peers may not react in a supportive manner to a youth’s disclosure, and disclosure may result in being kicked out, financial coercion, bullying, physical violence, or alienation. In these cases, youth may choose to delay disclosure until they are in a more supportive environment, and health care providers can play an important role in validating and affirming patients’ identities and maintaining confidentiality as appropriate. LGB youth should be counseled to consider the when, who, and how of their disclosure. They also should plan for how they might deal with a negative or rejecting response. Some tips are included below.⁵

When

•  You are ready.

•  You are comfortable with your identity.

•  You want to share information with people you trust and are close to.

•  You have a plan for support if you are not accepted (particularly when coming out to family).

Who

•  Someone you know well and expect to be supportive.

•  Someone you trust, feel safe with, and who can keep information confidential if needed (may need to explore school’s privacy and confidentiality policies if disclosing to a teacher or school personnel).

•  Be clear about who else information may be shared with and who NOT to share with.

How

•  Be sure you are prepared. You may want to talk to other sexual minority youth or adults who have come out, attend LGBTQ groups/forums, or seek out Internet resources to learn about others’ coming out experiences. These sources may serve as a support for you should you experience any negative or rejecting responses.

•  Make sure you have support resources in place prior to coming out.

•  Coming out by letter allows you time to carefully word what you want to say, and allows the other person time and privacy to consider their response.

•  If coming out in person, try to choose a quiet private space, and try to choose a time when everyone is relaxed and well-rested.

•  If concerned about your safety, make sure other people are immediately accessible if needed.

•  Plan what you are going to say, how you might end the conversation, and how you may want to talk about it later.

•  Listen actively to what the other person has to say.

•  Avoid any alcohol or drugs, as these may affect your mental and emotional state and responses.

•  Avoid coming out because of pressure from others or because you are angry.

Youth should be reminded that people’s responses may not always be predictable. It is important to note that for many individuals, coming out may be a lifelong process and occur in stages, beginning with close friends or family members and progressing from there. In the age of social media, youth should be reminded that disclosures through social media may be widely accessible, are easily shared, and may be difficult to remove. For youth who do not have supportive peer groups, and may not be able to disclose their sexual identity, providing support resources can be helpful.
 

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Resources for sexual minority youth and peers/families

Gay-Straight Alliance Network: gsanetwork.org

Gay Lesbian Straight Education Network: Information for Students: glsen.org/students

Sexuality Information and Education Council of the United States: www.siecus.org

The Trevor Project: Help and Suicide Prevention: www.thetrevorproject.org

It Gets Better Project: http://www.itgetsbetter.org/

Family and Ally Organization: PFLAG: https://www.pflag.org/

Advocates for Youth Parent Tips: http://www.advocatesforyouth.org/parents/173-parents

References

1. “Adolescent Sexuality,” by Michelle Forcier, MD, in Up to Date. Updated March 2017.

2. Pediatrics. 2016 Aug;138(2). pii: e20161348.

3. The Guidelines for Comprehensive Sexuality Education: Grades K-12 (Washington, D.C.: Sexuality Information and Education Council of the United States, 2004).

4. MMWR Surveillance Summaries, 2016, Aug 12;65(9):1-202.

5. “Sexual minority youth: Epidemiology and health concerns,” by Michelle Forcier, MD, and Johanna Olson-Kennedy, MD, in Up to Date.
 

Adolescence is a time of rapid growth and development both physically and emotionally. Some of the major tasks of adolescent development include developing a stable identity (this includes sexual and gender identity) and establishing independence from parents. This separation process from parents is often buffered by peer relationships. By the end of adolescence, those who are healthy and mature in their sexuality are able to:^1,2,3

•  Identify and live according to their own values and take responsibility for their behavior.

•  Practice effective decision-making, and develop critical-thinking skills.

•  Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.

•  Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.

•  Interact with all genders in respectful and appropriate ways.

•  Affirm their own gender identity and sexual orientation, and respect the gender identities and sexual orientations of others.

•  Appreciate their body and enjoy their sexuality throughout life, expressing sexuality in ways that are congruent with their values.

•  Express love and intimacy in appropriate ways.

•  Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.

•  Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.

Anywhere from 5% to 10% of teens identify as lesbian, gay, or bisexual (LGB).⁴ For these teens, the development of a sexual identity can add additional challenges to the development process, particularly if youth do not feel supported by family, peers, and their communities. Previous columns have addressed the role family acceptance can play in promoting the healthy development of sexual minority youth. Likewise, peer relationships also can play an important role in an adolescent’s development and health.

•  Acceptance.

•  Competence.

•  Higher levels of self-esteem and psychological well-being.

•  Strong sense of self and self-acceptance.

•  Strong ethnic identification.

•  Strong connections to family and school.

•  Caring adult role models outside the family.

•  Community involvement.

For some youth who may not be able receive acceptance from their families, peers and trusted adults may fill in this role and serve as a “chosen family.” A chosen family is commonly understood to mean a group of people who deliberately chose one another to play significant roles in each other’s lives even though they are not biologically or legally related. These relationships may be in addition to or in place of traditional family relationships. These connections can increase a youth’s sense of acceptance and connectedness and help promote resiliency.

Adolescents often may struggle on the decision of when to “come out” or disclose their sexual orientation to friends and family, and may ask their health care providers for advice. The number one consideration when making a decision about disclosure is safety. Unfortunately, some family members and peers may not react in a supportive manner to a youth’s disclosure, and disclosure may result in being kicked out, financial coercion, bullying, physical violence, or alienation. In these cases, youth may choose to delay disclosure until they are in a more supportive environment, and health care providers can play an important role in validating and affirming patients’ identities and maintaining confidentiality as appropriate. LGB youth should be counseled to consider the when, who, and how of their disclosure. They also should plan for how they might deal with a negative or rejecting response. Some tips are included below.⁵

When

•  You are ready.

•  You are comfortable with your identity.

•  You want to share information with people you trust and are close to.

•  You have a plan for support if you are not accepted (particularly when coming out to family).

Who

•  Someone you know well and expect to be supportive.

•  Someone you trust, feel safe with, and who can keep information confidential if needed (may need to explore school’s privacy and confidentiality policies if disclosing to a teacher or school personnel).

•  Be clear about who else information may be shared with and who NOT to share with.

How

•  Be sure you are prepared. You may want to talk to other sexual minority youth or adults who have come out, attend LGBTQ groups/forums, or seek out Internet resources to learn about others’ coming out experiences. These sources may serve as a support for you should you experience any negative or rejecting responses.

•  Make sure you have support resources in place prior to coming out.

•  Coming out by letter allows you time to carefully word what you want to say, and allows the other person time and privacy to consider their response.

•  If coming out in person, try to choose a quiet private space, and try to choose a time when everyone is relaxed and well-rested.

•  If concerned about your safety, make sure other people are immediately accessible if needed.

•  Plan what you are going to say, how you might end the conversation, and how you may want to talk about it later.

•  Listen actively to what the other person has to say.

•  Avoid any alcohol or drugs, as these may affect your mental and emotional state and responses.

•  Avoid coming out because of pressure from others or because you are angry.

Youth should be reminded that people’s responses may not always be predictable. It is important to note that for many individuals, coming out may be a lifelong process and occur in stages, beginning with close friends or family members and progressing from there. In the age of social media, youth should be reminded that disclosures through social media may be widely accessible, are easily shared, and may be difficult to remove. For youth who do not have supportive peer groups, and may not be able to disclose their sexual identity, providing support resources can be helpful.
 

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Resources for sexual minority youth and peers/families

Gay-Straight Alliance Network: gsanetwork.org

Gay Lesbian Straight Education Network: Information for Students: glsen.org/students

Sexuality Information and Education Council of the United States: www.siecus.org

The Trevor Project: Help and Suicide Prevention: www.thetrevorproject.org

It Gets Better Project: http://www.itgetsbetter.org/

Family and Ally Organization: PFLAG: https://www.pflag.org/

Advocates for Youth Parent Tips: http://www.advocatesforyouth.org/parents/173-parents

References

1. “Adolescent Sexuality,” by Michelle Forcier, MD, in Up to Date. Updated March 2017.

2. Pediatrics. 2016 Aug;138(2). pii: e20161348.

3. The Guidelines for Comprehensive Sexuality Education: Grades K-12 (Washington, D.C.: Sexuality Information and Education Council of the United States, 2004).

4. MMWR Surveillance Summaries, 2016, Aug 12;65(9):1-202.

5. “Sexual minority youth: Epidemiology and health concerns,” by Michelle Forcier, MD, and Johanna Olson-Kennedy, MD, in Up to Date.
 

Adolescence is a time of rapid growth and development both physically and emotionally. Some of the major tasks of adolescent development include developing a stable identity (this includes sexual and gender identity) and establishing independence from parents. This separation process from parents is often buffered by peer relationships. By the end of adolescence, those who are healthy and mature in their sexuality are able to:^1,2,3

•  Identify and live according to their own values and take responsibility for their behavior.

•  Practice effective decision-making, and develop critical-thinking skills.

•  Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.

•  Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.

•  Interact with all genders in respectful and appropriate ways.

•  Affirm their own gender identity and sexual orientation, and respect the gender identities and sexual orientations of others.

•  Appreciate their body and enjoy their sexuality throughout life, expressing sexuality in ways that are congruent with their values.

•  Express love and intimacy in appropriate ways.

•  Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.

•  Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.

Anywhere from 5% to 10% of teens identify as lesbian, gay, or bisexual (LGB).⁴ For these teens, the development of a sexual identity can add additional challenges to the development process, particularly if youth do not feel supported by family, peers, and their communities. Previous columns have addressed the role family acceptance can play in promoting the healthy development of sexual minority youth. Likewise, peer relationships also can play an important role in an adolescent’s development and health.

•  Acceptance.

•  Competence.

•  Higher levels of self-esteem and psychological well-being.

•  Strong sense of self and self-acceptance.

•  Strong ethnic identification.

•  Strong connections to family and school.

•  Caring adult role models outside the family.

•  Community involvement.

For some youth who may not be able receive acceptance from their families, peers and trusted adults may fill in this role and serve as a “chosen family.” A chosen family is commonly understood to mean a group of people who deliberately chose one another to play significant roles in each other’s lives even though they are not biologically or legally related. These relationships may be in addition to or in place of traditional family relationships. These connections can increase a youth’s sense of acceptance and connectedness and help promote resiliency.

Adolescents often may struggle on the decision of when to “come out” or disclose their sexual orientation to friends and family, and may ask their health care providers for advice. The number one consideration when making a decision about disclosure is safety. Unfortunately, some family members and peers may not react in a supportive manner to a youth’s disclosure, and disclosure may result in being kicked out, financial coercion, bullying, physical violence, or alienation. In these cases, youth may choose to delay disclosure until they are in a more supportive environment, and health care providers can play an important role in validating and affirming patients’ identities and maintaining confidentiality as appropriate. LGB youth should be counseled to consider the when, who, and how of their disclosure. They also should plan for how they might deal with a negative or rejecting response. Some tips are included below.⁵

When

•  You are ready.

•  You are comfortable with your identity.

•  You want to share information with people you trust and are close to.

•  You have a plan for support if you are not accepted (particularly when coming out to family).

Who

•  Someone you know well and expect to be supportive.

•  Someone you trust, feel safe with, and who can keep information confidential if needed (may need to explore school’s privacy and confidentiality policies if disclosing to a teacher or school personnel).

•  Be clear about who else information may be shared with and who NOT to share with.

How

•  Be sure you are prepared. You may want to talk to other sexual minority youth or adults who have come out, attend LGBTQ groups/forums, or seek out Internet resources to learn about others’ coming out experiences. These sources may serve as a support for you should you experience any negative or rejecting responses.

•  Make sure you have support resources in place prior to coming out.

•  Coming out by letter allows you time to carefully word what you want to say, and allows the other person time and privacy to consider their response.

•  If coming out in person, try to choose a quiet private space, and try to choose a time when everyone is relaxed and well-rested.

•  If concerned about your safety, make sure other people are immediately accessible if needed.

•  Plan what you are going to say, how you might end the conversation, and how you may want to talk about it later.

•  Listen actively to what the other person has to say.

•  Avoid any alcohol or drugs, as these may affect your mental and emotional state and responses.

•  Avoid coming out because of pressure from others or because you are angry.

Youth should be reminded that people’s responses may not always be predictable. It is important to note that for many individuals, coming out may be a lifelong process and occur in stages, beginning with close friends or family members and progressing from there. In the age of social media, youth should be reminded that disclosures through social media may be widely accessible, are easily shared, and may be difficult to remove. For youth who do not have supportive peer groups, and may not be able to disclose their sexual identity, providing support resources can be helpful.
 

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Resources for sexual minority youth and peers/families

Gay-Straight Alliance Network: gsanetwork.org

Gay Lesbian Straight Education Network: Information for Students: glsen.org/students

Sexuality Information and Education Council of the United States: www.siecus.org

The Trevor Project: Help and Suicide Prevention: www.thetrevorproject.org

It Gets Better Project: http://www.itgetsbetter.org/

Family and Ally Organization: PFLAG: https://www.pflag.org/

Advocates for Youth Parent Tips: http://www.advocatesforyouth.org/parents/173-parents

References

1. “Adolescent Sexuality,” by Michelle Forcier, MD, in Up to Date. Updated March 2017.

2. Pediatrics. 2016 Aug;138(2). pii: e20161348.

3. The Guidelines for Comprehensive Sexuality Education: Grades K-12 (Washington, D.C.: Sexuality Information and Education Council of the United States, 2004).

4. MMWR Surveillance Summaries, 2016, Aug 12;65(9):1-202.

5. “Sexual minority youth: Epidemiology and health concerns,” by Michelle Forcier, MD, and Johanna Olson-Kennedy, MD, in Up to Date.
 

Lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ) youth face bias and discrimination within the health care setting and experience disparities in health, compared with their heterosexual cisgender peers. This is an area that is receiving increasing attention and study as health care providers and researchers work to achieve health equity within these populations.

Studies focusing specifically on the health of bisexual youth and adults are lacking. The few that do exist suggest that the experiences of people who identify as bisexual may be different from those who identify as lesbian or gay. Myths and misconceptions about bisexual, pansexual, queer, and fluid identities may in some cases put these populations at increased risks. Common myths include that bisexuality is just a phase or that youth who identify as bisexual are just confused. Studies suggest that bisexual youth account for almost half of youth who identify as LGBTQ. Understanding more about some of the challenges bisexual youth and adults may face can help us better care for all of our patients and families.

• Bisexual adults are more likely to engage in self-harming behaviors, attempt suicide, or think about suicide than heterosexual adults, lesbian women, or gay men.¹

• Bisexual women have higher rates of high blood pressure, compared with heterosexual and lesbian women.²

• Bisexual women have higher rates of alcohol-related disorders than lesbian and heterosexual women.¹

Some disparities appear to be related to lack of preventive care. A survey by the Williams Institute found that 39% of bisexual men and 33% of bisexual women did not disclose their sexual orientation, compared with 13% of gay men and 10% of lesbian women.¹ The effect of intersecting identities also must be considered when discussing these health disparities. More than 40% of LGBTQ people of color identify as bisexual, and almost half of transgender people describe their sexual orientation as bisexual or queer.¹ These individuals may be especially vulnerable to health disparities as they may experience a combination of racism, transphobia, and biphobia.

Risk factors for these disparities may develop early in life. A 2012 survey of LGBTQ youth found that:³

• Bisexual youth were less likely than lesbian and gay youth to report having supportive adults who they could turn to if they were sad.

• Only 5% of bisexual youth reported being very happy, compared with 8% of gay and lesbian youth and 21% of non-LGBT youth.

• Bisexual youth reported higher rates of experimentation with drugs and alcohol, compared with their lesbian, gay, and heterosexual peers.

• Bisexual youth reported lower levels of family acceptance and knowledge of social support systems in their communities than lesbian and gay youth. Both family acceptance and knowledge of social support systems have been identified as protective factors in the development of youth.

• Bisexual youth are less likely to be out to their friends, families, and communities.

As health care providers, recognizing, respecting, and supporting the identities of our bisexual patients is important. A few simple things we can do in practice are as follows:

• Don’t mislabel patients as lesbian, gay, or straight when they have disclosed a bisexual identity.

• Don’t assume that bisexuality is just a phase or that youths are confused when they disclose their identity.

• Don’t assume you know a patient’s sexual orientation or behaviors on the basis of the sex of the current partner or current behaviors.

• Do ask open and nonjudgmental questions about sexual attraction and behaviors, and be familiar with the terms bisexual, queer, questioning, and pansexual in addition to lesbian, gay, and straight.

• Do use inclusive terms like LGBT when referring to the community rather than gay rights.

• Do recognize potential biases and assumptions regarding sexuality and bisexuality and work to change them.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Terms and definitions:

Bisexual – A person who can be attracted to more than one sex, gender, or gender identity. “Bi” is often used as an abbreviation.

Biphobia – Prejudice, fear, or hatred directed toward bisexual people.

Queer – A term people often use to express fluid identities and orientations. Historically considered a pejorative term, but used by many youth to describe their identity.

Pansexual – A person who can be attracted to any sex, gender, or gender identity.

References:
 

1. ”Health Disparities Among Bisexual People,” brief by the Human Rights Campaign Foundation.

2. “New Mexico’s Progress in Collecting Lesbian, Gay, Bisexual, and Transgender Health Data and Its Implications for Addressing Health Disparities,” New Mexico Department of Health, April 2010.

3. “Supporting and Caring for Our Bisexual Youth,” the Human Rights Campaign Foundation, 2014.

Lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ) youth face bias and discrimination within the health care setting and experience disparities in health, compared with their heterosexual cisgender peers. This is an area that is receiving increasing attention and study as health care providers and researchers work to achieve health equity within these populations.

Studies focusing specifically on the health of bisexual youth and adults are lacking. The few that do exist suggest that the experiences of people who identify as bisexual may be different from those who identify as lesbian or gay. Myths and misconceptions about bisexual, pansexual, queer, and fluid identities may in some cases put these populations at increased risks. Common myths include that bisexuality is just a phase or that youth who identify as bisexual are just confused. Studies suggest that bisexual youth account for almost half of youth who identify as LGBTQ. Understanding more about some of the challenges bisexual youth and adults may face can help us better care for all of our patients and families.

• Bisexual adults are more likely to engage in self-harming behaviors, attempt suicide, or think about suicide than heterosexual adults, lesbian women, or gay men.¹

• Bisexual women have higher rates of high blood pressure, compared with heterosexual and lesbian women.²

• Bisexual women have higher rates of alcohol-related disorders than lesbian and heterosexual women.¹

Some disparities appear to be related to lack of preventive care. A survey by the Williams Institute found that 39% of bisexual men and 33% of bisexual women did not disclose their sexual orientation, compared with 13% of gay men and 10% of lesbian women.¹ The effect of intersecting identities also must be considered when discussing these health disparities. More than 40% of LGBTQ people of color identify as bisexual, and almost half of transgender people describe their sexual orientation as bisexual or queer.¹ These individuals may be especially vulnerable to health disparities as they may experience a combination of racism, transphobia, and biphobia.

Risk factors for these disparities may develop early in life. A 2012 survey of LGBTQ youth found that:³

• Bisexual youth were less likely than lesbian and gay youth to report having supportive adults who they could turn to if they were sad.

• Only 5% of bisexual youth reported being very happy, compared with 8% of gay and lesbian youth and 21% of non-LGBT youth.

• Bisexual youth reported higher rates of experimentation with drugs and alcohol, compared with their lesbian, gay, and heterosexual peers.

• Bisexual youth reported lower levels of family acceptance and knowledge of social support systems in their communities than lesbian and gay youth. Both family acceptance and knowledge of social support systems have been identified as protective factors in the development of youth.

• Bisexual youth are less likely to be out to their friends, families, and communities.

As health care providers, recognizing, respecting, and supporting the identities of our bisexual patients is important. A few simple things we can do in practice are as follows:

• Don’t mislabel patients as lesbian, gay, or straight when they have disclosed a bisexual identity.

• Don’t assume that bisexuality is just a phase or that youths are confused when they disclose their identity.

• Don’t assume you know a patient’s sexual orientation or behaviors on the basis of the sex of the current partner or current behaviors.

• Do ask open and nonjudgmental questions about sexual attraction and behaviors, and be familiar with the terms bisexual, queer, questioning, and pansexual in addition to lesbian, gay, and straight.

• Do use inclusive terms like LGBT when referring to the community rather than gay rights.

• Do recognize potential biases and assumptions regarding sexuality and bisexuality and work to change them.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Terms and definitions:

Bisexual – A person who can be attracted to more than one sex, gender, or gender identity. “Bi” is often used as an abbreviation.

Biphobia – Prejudice, fear, or hatred directed toward bisexual people.

Queer – A term people often use to express fluid identities and orientations. Historically considered a pejorative term, but used by many youth to describe their identity.

Pansexual – A person who can be attracted to any sex, gender, or gender identity.

References:
 

1. ”Health Disparities Among Bisexual People,” brief by the Human Rights Campaign Foundation.

2. “New Mexico’s Progress in Collecting Lesbian, Gay, Bisexual, and Transgender Health Data and Its Implications for Addressing Health Disparities,” New Mexico Department of Health, April 2010.

3. “Supporting and Caring for Our Bisexual Youth,” the Human Rights Campaign Foundation, 2014.

Lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ) youth face bias and discrimination within the health care setting and experience disparities in health, compared with their heterosexual cisgender peers. This is an area that is receiving increasing attention and study as health care providers and researchers work to achieve health equity within these populations.

Studies focusing specifically on the health of bisexual youth and adults are lacking. The few that do exist suggest that the experiences of people who identify as bisexual may be different from those who identify as lesbian or gay. Myths and misconceptions about bisexual, pansexual, queer, and fluid identities may in some cases put these populations at increased risks. Common myths include that bisexuality is just a phase or that youth who identify as bisexual are just confused. Studies suggest that bisexual youth account for almost half of youth who identify as LGBTQ. Understanding more about some of the challenges bisexual youth and adults may face can help us better care for all of our patients and families.

• Bisexual adults are more likely to engage in self-harming behaviors, attempt suicide, or think about suicide than heterosexual adults, lesbian women, or gay men.¹

• Bisexual women have higher rates of high blood pressure, compared with heterosexual and lesbian women.²

• Bisexual women have higher rates of alcohol-related disorders than lesbian and heterosexual women.¹

Some disparities appear to be related to lack of preventive care. A survey by the Williams Institute found that 39% of bisexual men and 33% of bisexual women did not disclose their sexual orientation, compared with 13% of gay men and 10% of lesbian women.¹ The effect of intersecting identities also must be considered when discussing these health disparities. More than 40% of LGBTQ people of color identify as bisexual, and almost half of transgender people describe their sexual orientation as bisexual or queer.¹ These individuals may be especially vulnerable to health disparities as they may experience a combination of racism, transphobia, and biphobia.

Risk factors for these disparities may develop early in life. A 2012 survey of LGBTQ youth found that:³

• Bisexual youth were less likely than lesbian and gay youth to report having supportive adults who they could turn to if they were sad.

• Only 5% of bisexual youth reported being very happy, compared with 8% of gay and lesbian youth and 21% of non-LGBT youth.

• Bisexual youth reported higher rates of experimentation with drugs and alcohol, compared with their lesbian, gay, and heterosexual peers.

• Bisexual youth reported lower levels of family acceptance and knowledge of social support systems in their communities than lesbian and gay youth. Both family acceptance and knowledge of social support systems have been identified as protective factors in the development of youth.

• Bisexual youth are less likely to be out to their friends, families, and communities.

As health care providers, recognizing, respecting, and supporting the identities of our bisexual patients is important. A few simple things we can do in practice are as follows:

• Don’t mislabel patients as lesbian, gay, or straight when they have disclosed a bisexual identity.

• Don’t assume that bisexuality is just a phase or that youths are confused when they disclose their identity.

• Don’t assume you know a patient’s sexual orientation or behaviors on the basis of the sex of the current partner or current behaviors.

• Do ask open and nonjudgmental questions about sexual attraction and behaviors, and be familiar with the terms bisexual, queer, questioning, and pansexual in addition to lesbian, gay, and straight.

• Do use inclusive terms like LGBT when referring to the community rather than gay rights.

• Do recognize potential biases and assumptions regarding sexuality and bisexuality and work to change them.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Terms and definitions:

Bisexual – A person who can be attracted to more than one sex, gender, or gender identity. “Bi” is often used as an abbreviation.

Biphobia – Prejudice, fear, or hatred directed toward bisexual people.

Queer – A term people often use to express fluid identities and orientations. Historically considered a pejorative term, but used by many youth to describe their identity.

Pansexual – A person who can be attracted to any sex, gender, or gender identity.

References:
 

1. ”Health Disparities Among Bisexual People,” brief by the Human Rights Campaign Foundation.

2. “New Mexico’s Progress in Collecting Lesbian, Gay, Bisexual, and Transgender Health Data and Its Implications for Addressing Health Disparities,” New Mexico Department of Health, April 2010.

3. “Supporting and Caring for Our Bisexual Youth,” the Human Rights Campaign Foundation, 2014.

For many the beginning of a new year is a time to set goals and resolutions for the upcoming year. Often these resolutions are related to health, for example, quit smoking, work out more, lose weight. It is sometimes easy to overlook mental health and well-being as an integral part of overall wellness. This month’s column will focus on how as pediatric providers we can help promote the mental well-being of our patients in practice.

Mental health problems are a significant cause of morbidity and mortality in youth. In 2014, suicide was the second leading cause of death for all youth 10-14 years and 15-24 years.¹ While most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) persons live healthy, happy lives, LGBTQ youth are at disproportionate risk for mental illness, probably related to lack of support and to stigma related to their sexual minority and gender minority identities. Studies suggest that LGBTQ youth have suicidality rates two to five times higher than their heterosexual cisgender peers.^2,3,4

• Principle 1. A comprehensive diagnostic evaluation should include an age-appropriate assessment of psychosexual development for all youths.

While pediatric providers are unlikely to perform a comprehensive mental health diagnostic evaluation, psychosocial development should regularly be assessed at well visits. It may not be readily apparent which youth are struggling with development of their sexual and gender identity. Nonassuming questions regarding development in theses domains should ideally be integrated into the psychosocial assessment. For example, begin a sexual history by asking, “Are you romantically attracted to males, females, both, or neither?”

• Principle 2. The need for confidentiality in the clinical alliance is a special consideration in the assessment of sexual and gender minority youth.

Confidentiality is important when talking to any youth about their sexual and gender identity. LGBTQ youth in particular may have concerns of family or provider rejection, and they may look for cues that they can safely discuss their sexuality or gender identity without fear of being judged or shamed. Clinicians should be aware of confidentiality practices for minors when discussing these issues. Potential risks of premature disclosure to family and support systems, such as rejection or alienation, also should be considered.

• Principle 3. Family dynamics pertinent to sexual orientation, gender nonconformity, and gender identity should be explored in the context of the cultural values of the youth, family, and community.

Families can have a variety of responses to their child’s sexual minority or gender minority identity, ranging from acceptance to rejection, with some youth being forced to leave home. Many families need to alter their ideas and expectations for a child after their child comes out, and this can lead to feelings of loss and grief accompanied by feelings of anxiety, anger, shame, and guilt.⁵ Over time, however, the majority of families become affirming and supportive and are not distressed.⁷ Recognizing that family support reduces negative health outcomes for youth, providers should aim to support and preserve positive family relationships when possible. This may involve education and support for families as well as youth. It is important to be aware that sexual and gender minority youth who are also members of ethnic minorities may face additional challenges.

• Principle 4. Clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased psychiatric risk.

Providers should recognize that LGBTQ youth are at disproportionate risk of bullying, suicide, substance use, high-risk sexual behaviors, running away, and becoming homeless. Providers should assess for these risks and address them as appropriate.

• Principle 5. Clinicians should aim to foster healthy psychosexual development in sexual and gender minority youth, and protect these individuals’ full capacity for integrated identity formation and functioning.

Providers should support healthy youth development and self-discovery, recognizing that there is a spectrum of sexual and gender identities, with the goal of helping youth achieve their full developmental potential.

• Principle 6. Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and attempts to do so may be harmful.

Therapies targeted at altering sexual orientation or gender identity, often referred to as reparative therapies, can encourage family rejection and decrease self-esteem and connectedness, all of which have been identified as risk factors for suicidality. Providers should educate parents about the potential harm of these types of therapies and ensure that mental health providers to whom patients are being referred are not practicing these potentially harmful therapies.

• Principle 7. Clinicians should be aware of current evidence on the natural course of gender discordance and associated psychopathology in children and adolescents in choosing the treatment goals and modality.

Variation in gender role behavior (for example, dress preference, toy preference, types of play) is typical in early childhood and should be distinguished from gender dysphoria, in which a child expresses distress related to a gender identity that is different from or does not fully align with the child’s sex assigned at birth. Assessing gender development in childhood and the best approach to treatment is best done by professionals with experience and training in gender development, and providers should be familiar with resources in their area. For some, gender identity concerns may not be recognized until adolescence when the onset of puberty and secondary sex characteristics result in increased dysphoria. Best practice guidelines exist for treatment of youth with gender discordance, and there is limited but growing evidence to support best practices. Providers should ensure that the providers and specialists to whom families are referred practice according to current best practices.

• Principle 8. Clinicians should be prepared to consult and act as a liaison with schools, community agencies, and other health care providers, advocating for the unique needs of sexual and gender minority youth and their families.

Pediatric providers can work with mental health professionals to be advocates for their gender and sexual minority patients and raise awareness of issues affecting these special populations such as bullying and suicidality.

• Principle 9. Mental health professionals should be aware of community and professional resources relevant to sexual and gender minority youth.

As medical providers, we have a limited amount of time to see and assess patients, and often are able to best serve our patients and families by connecting them to specialists in the medical community and resources available in the school and community. It is important to know what resources exist in the community to be able to appropriately refer and connect patients.

Resources for providers

• American Academy of Child and Adolescent Psychiatry Practice Parameter on lesbian, gay, bisexual, and transgender youth .

• National LGBT Health Education Center: Training materials and modules with continuing education credits.

Resources for families

• Gay, Lesbian, and Straight Education Network.• Parents, Friends, Families of Lesbians and Gays (PFLAG).

References

1. “10 Leading Causes of Death by Age Group, United States – 2014,” National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

2. Lesbian, Gay, Bisexual, and Transgender Health: LGBT Youth, Centers for Disease Control and Prevention, Nov. 12, 2014.

3. Am J Public Health. 2001 Aug;91(8):1276-81.

4. Am J Prev Med. 2012 Mar;42(3):221-8.

5. J. Am Acad Child Adolesc Psychiatry. 2012;51(9):957–74.

6. Pediatr Clin North Am. 2016 Dec;63(6):971-83.

7. “Mom, Dad. I’m Gay: How Families Negotiate Coming Out” (Washington, DC: American Psychological Association, 2001).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

For many the beginning of a new year is a time to set goals and resolutions for the upcoming year. Often these resolutions are related to health, for example, quit smoking, work out more, lose weight. It is sometimes easy to overlook mental health and well-being as an integral part of overall wellness. This month’s column will focus on how as pediatric providers we can help promote the mental well-being of our patients in practice.

Mental health problems are a significant cause of morbidity and mortality in youth. In 2014, suicide was the second leading cause of death for all youth 10-14 years and 15-24 years.¹ While most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) persons live healthy, happy lives, LGBTQ youth are at disproportionate risk for mental illness, probably related to lack of support and to stigma related to their sexual minority and gender minority identities. Studies suggest that LGBTQ youth have suicidality rates two to five times higher than their heterosexual cisgender peers.^2,3,4

• Principle 1. A comprehensive diagnostic evaluation should include an age-appropriate assessment of psychosexual development for all youths.

While pediatric providers are unlikely to perform a comprehensive mental health diagnostic evaluation, psychosocial development should regularly be assessed at well visits. It may not be readily apparent which youth are struggling with development of their sexual and gender identity. Nonassuming questions regarding development in theses domains should ideally be integrated into the psychosocial assessment. For example, begin a sexual history by asking, “Are you romantically attracted to males, females, both, or neither?”

• Principle 2. The need for confidentiality in the clinical alliance is a special consideration in the assessment of sexual and gender minority youth.

Confidentiality is important when talking to any youth about their sexual and gender identity. LGBTQ youth in particular may have concerns of family or provider rejection, and they may look for cues that they can safely discuss their sexuality or gender identity without fear of being judged or shamed. Clinicians should be aware of confidentiality practices for minors when discussing these issues. Potential risks of premature disclosure to family and support systems, such as rejection or alienation, also should be considered.

• Principle 3. Family dynamics pertinent to sexual orientation, gender nonconformity, and gender identity should be explored in the context of the cultural values of the youth, family, and community.

Families can have a variety of responses to their child’s sexual minority or gender minority identity, ranging from acceptance to rejection, with some youth being forced to leave home. Many families need to alter their ideas and expectations for a child after their child comes out, and this can lead to feelings of loss and grief accompanied by feelings of anxiety, anger, shame, and guilt.⁵ Over time, however, the majority of families become affirming and supportive and are not distressed.⁷ Recognizing that family support reduces negative health outcomes for youth, providers should aim to support and preserve positive family relationships when possible. This may involve education and support for families as well as youth. It is important to be aware that sexual and gender minority youth who are also members of ethnic minorities may face additional challenges.

• Principle 4. Clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased psychiatric risk.

Providers should recognize that LGBTQ youth are at disproportionate risk of bullying, suicide, substance use, high-risk sexual behaviors, running away, and becoming homeless. Providers should assess for these risks and address them as appropriate.

• Principle 5. Clinicians should aim to foster healthy psychosexual development in sexual and gender minority youth, and protect these individuals’ full capacity for integrated identity formation and functioning.

Providers should support healthy youth development and self-discovery, recognizing that there is a spectrum of sexual and gender identities, with the goal of helping youth achieve their full developmental potential.

• Principle 6. Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and attempts to do so may be harmful.

Therapies targeted at altering sexual orientation or gender identity, often referred to as reparative therapies, can encourage family rejection and decrease self-esteem and connectedness, all of which have been identified as risk factors for suicidality. Providers should educate parents about the potential harm of these types of therapies and ensure that mental health providers to whom patients are being referred are not practicing these potentially harmful therapies.

• Principle 7. Clinicians should be aware of current evidence on the natural course of gender discordance and associated psychopathology in children and adolescents in choosing the treatment goals and modality.

Variation in gender role behavior (for example, dress preference, toy preference, types of play) is typical in early childhood and should be distinguished from gender dysphoria, in which a child expresses distress related to a gender identity that is different from or does not fully align with the child’s sex assigned at birth. Assessing gender development in childhood and the best approach to treatment is best done by professionals with experience and training in gender development, and providers should be familiar with resources in their area. For some, gender identity concerns may not be recognized until adolescence when the onset of puberty and secondary sex characteristics result in increased dysphoria. Best practice guidelines exist for treatment of youth with gender discordance, and there is limited but growing evidence to support best practices. Providers should ensure that the providers and specialists to whom families are referred practice according to current best practices.

• Principle 8. Clinicians should be prepared to consult and act as a liaison with schools, community agencies, and other health care providers, advocating for the unique needs of sexual and gender minority youth and their families.

Pediatric providers can work with mental health professionals to be advocates for their gender and sexual minority patients and raise awareness of issues affecting these special populations such as bullying and suicidality.

• Principle 9. Mental health professionals should be aware of community and professional resources relevant to sexual and gender minority youth.

As medical providers, we have a limited amount of time to see and assess patients, and often are able to best serve our patients and families by connecting them to specialists in the medical community and resources available in the school and community. It is important to know what resources exist in the community to be able to appropriately refer and connect patients.

Resources for providers

• American Academy of Child and Adolescent Psychiatry Practice Parameter on lesbian, gay, bisexual, and transgender youth .

• National LGBT Health Education Center: Training materials and modules with continuing education credits.

Resources for families

• Gay, Lesbian, and Straight Education Network.• Parents, Friends, Families of Lesbians and Gays (PFLAG).

References

1. “10 Leading Causes of Death by Age Group, United States – 2014,” National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

2. Lesbian, Gay, Bisexual, and Transgender Health: LGBT Youth, Centers for Disease Control and Prevention, Nov. 12, 2014.

3. Am J Public Health. 2001 Aug;91(8):1276-81.

4. Am J Prev Med. 2012 Mar;42(3):221-8.

5. J. Am Acad Child Adolesc Psychiatry. 2012;51(9):957–74.

6. Pediatr Clin North Am. 2016 Dec;63(6):971-83.

7. “Mom, Dad. I’m Gay: How Families Negotiate Coming Out” (Washington, DC: American Psychological Association, 2001).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

For many the beginning of a new year is a time to set goals and resolutions for the upcoming year. Often these resolutions are related to health, for example, quit smoking, work out more, lose weight. It is sometimes easy to overlook mental health and well-being as an integral part of overall wellness. This month’s column will focus on how as pediatric providers we can help promote the mental well-being of our patients in practice.

Mental health problems are a significant cause of morbidity and mortality in youth. In 2014, suicide was the second leading cause of death for all youth 10-14 years and 15-24 years.¹ While most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) persons live healthy, happy lives, LGBTQ youth are at disproportionate risk for mental illness, probably related to lack of support and to stigma related to their sexual minority and gender minority identities. Studies suggest that LGBTQ youth have suicidality rates two to five times higher than their heterosexual cisgender peers.^2,3,4

• Principle 1. A comprehensive diagnostic evaluation should include an age-appropriate assessment of psychosexual development for all youths.

While pediatric providers are unlikely to perform a comprehensive mental health diagnostic evaluation, psychosocial development should regularly be assessed at well visits. It may not be readily apparent which youth are struggling with development of their sexual and gender identity. Nonassuming questions regarding development in theses domains should ideally be integrated into the psychosocial assessment. For example, begin a sexual history by asking, “Are you romantically attracted to males, females, both, or neither?”

• Principle 2. The need for confidentiality in the clinical alliance is a special consideration in the assessment of sexual and gender minority youth.

Confidentiality is important when talking to any youth about their sexual and gender identity. LGBTQ youth in particular may have concerns of family or provider rejection, and they may look for cues that they can safely discuss their sexuality or gender identity without fear of being judged or shamed. Clinicians should be aware of confidentiality practices for minors when discussing these issues. Potential risks of premature disclosure to family and support systems, such as rejection or alienation, also should be considered.

• Principle 3. Family dynamics pertinent to sexual orientation, gender nonconformity, and gender identity should be explored in the context of the cultural values of the youth, family, and community.

Families can have a variety of responses to their child’s sexual minority or gender minority identity, ranging from acceptance to rejection, with some youth being forced to leave home. Many families need to alter their ideas and expectations for a child after their child comes out, and this can lead to feelings of loss and grief accompanied by feelings of anxiety, anger, shame, and guilt.⁵ Over time, however, the majority of families become affirming and supportive and are not distressed.⁷ Recognizing that family support reduces negative health outcomes for youth, providers should aim to support and preserve positive family relationships when possible. This may involve education and support for families as well as youth. It is important to be aware that sexual and gender minority youth who are also members of ethnic minorities may face additional challenges.

• Principle 4. Clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased psychiatric risk.

Providers should recognize that LGBTQ youth are at disproportionate risk of bullying, suicide, substance use, high-risk sexual behaviors, running away, and becoming homeless. Providers should assess for these risks and address them as appropriate.

• Principle 5. Clinicians should aim to foster healthy psychosexual development in sexual and gender minority youth, and protect these individuals’ full capacity for integrated identity formation and functioning.

Providers should support healthy youth development and self-discovery, recognizing that there is a spectrum of sexual and gender identities, with the goal of helping youth achieve their full developmental potential.

• Principle 6. Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and attempts to do so may be harmful.

Therapies targeted at altering sexual orientation or gender identity, often referred to as reparative therapies, can encourage family rejection and decrease self-esteem and connectedness, all of which have been identified as risk factors for suicidality. Providers should educate parents about the potential harm of these types of therapies and ensure that mental health providers to whom patients are being referred are not practicing these potentially harmful therapies.

• Principle 7. Clinicians should be aware of current evidence on the natural course of gender discordance and associated psychopathology in children and adolescents in choosing the treatment goals and modality.

Variation in gender role behavior (for example, dress preference, toy preference, types of play) is typical in early childhood and should be distinguished from gender dysphoria, in which a child expresses distress related to a gender identity that is different from or does not fully align with the child’s sex assigned at birth. Assessing gender development in childhood and the best approach to treatment is best done by professionals with experience and training in gender development, and providers should be familiar with resources in their area. For some, gender identity concerns may not be recognized until adolescence when the onset of puberty and secondary sex characteristics result in increased dysphoria. Best practice guidelines exist for treatment of youth with gender discordance, and there is limited but growing evidence to support best practices. Providers should ensure that the providers and specialists to whom families are referred practice according to current best practices.

• Principle 8. Clinicians should be prepared to consult and act as a liaison with schools, community agencies, and other health care providers, advocating for the unique needs of sexual and gender minority youth and their families.

Pediatric providers can work with mental health professionals to be advocates for their gender and sexual minority patients and raise awareness of issues affecting these special populations such as bullying and suicidality.

• Principle 9. Mental health professionals should be aware of community and professional resources relevant to sexual and gender minority youth.

As medical providers, we have a limited amount of time to see and assess patients, and often are able to best serve our patients and families by connecting them to specialists in the medical community and resources available in the school and community. It is important to know what resources exist in the community to be able to appropriately refer and connect patients.

Resources for providers

• American Academy of Child and Adolescent Psychiatry Practice Parameter on lesbian, gay, bisexual, and transgender youth .

• National LGBT Health Education Center: Training materials and modules with continuing education credits.

Resources for families

• Gay, Lesbian, and Straight Education Network.• Parents, Friends, Families of Lesbians and Gays (PFLAG).

References

1. “10 Leading Causes of Death by Age Group, United States – 2014,” National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

2. Lesbian, Gay, Bisexual, and Transgender Health: LGBT Youth, Centers for Disease Control and Prevention, Nov. 12, 2014.

3. Am J Public Health. 2001 Aug;91(8):1276-81.

4. Am J Prev Med. 2012 Mar;42(3):221-8.

5. J. Am Acad Child Adolesc Psychiatry. 2012;51(9):957–74.

6. Pediatr Clin North Am. 2016 Dec;63(6):971-83.

7. “Mom, Dad. I’m Gay: How Families Negotiate Coming Out” (Washington, DC: American Psychological Association, 2001).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

The Centers for Disease Control and Prevention released results from the first nationally representative study on health risk behaviors of gay, lesbian, and bisexual (GLB) high school students in August 2016.

These data were collected through the Youth Risk Behavior Survey (YRBS) questionnaire. The YRBS questionnaire was developed in 1990 as a way to monitor health-related behaviors that contribute to the leading causes of mortality and morbidity in youth and young adults. Areas covered by the survey include behaviors related to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, and physical activity. Data are collected every 2 years through national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th-12th grade students.

Selected questionnaire results

Sexual identity

• 88.8% of students identified as heterosexual.

• 6.0% identified as bisexual.

• 3.2% were not sure.

• 2.0% identified as gay or lesbian.

Sexual behaviors

• 48% had had sexual contact with the opposite sex only.

• 4.6% had sexual contact with both sexes.

• 1.7% had had sexual contact with the same sex only.

• 45.7% had no sexual contact.

Mental health

Percent of students who reported making a suicide plan in the 12 months preceding the survey:

• 11.9% of heterosexual students.

• 27.9% of students not sure of sexual identity.

• 38.2% of gay, lesbian, bisexual (GLB) students.

Percent of students who attempted suicide in the 12 months preceding the survey:

• 6.4% of heterosexual students.

• 13.7% of students not sure of sexual identity.

• 29.4% of GLB students.

Sexual Behaviors

First sex before the age of 13:

• 3.4% of heterosexual students.

• 8.8% of students not sure of their sexual identity.

• 7.3% of GLB students.

Drank alcohol or used drugs before last sex:

• 20.0% of heterosexual students.

• 44.5% of students not sure of their sexual identity.

• 22.4% of GLB students.

Tested for HIV:

• 9.3% of heterosexual students.

• 12.8% of students not sure of their sexual identity.

• 18.2% of GLB students.

Substance use

Currently smoking cigarettes daily:

• 1.9% of heterosexual students.

• 7.0% of students not sure of their sexual identity.

• 4.0% of GLB students.

Current alcohol use:

• 32.1% of heterosexual students.

• 34.6% of students not sure of their sexual identity.

• 40.5% of GLB students.

Current marijuana use:

• 20.7% of heterosexual students.

• 26.0% of students not sure of their sexual identity.

• 32.0% of GLB students.

Used hallucinogenic drugs (such as LSD, acid, PCP, angel dust, mescaline, or mushrooms):

• 5.5% of heterosexual students.

• 15.7% of students not sure of their sexual identity.

• 11.5% of GLB students.

Ever used heroin:

• 1.3% of heterosexual students.

• 9.3% of students not sure of their sexual identity.

• 6.0% of GLB students.

Ever took prescription drugs without a doctor’s prescription:

15.5% of heterosexual students.

24.3% of students not sure of their sexual identity.

27.5% of GLB students.

Physical Activity

Did not participate in at least 60 minutes of physical activity on at least 1 day in past week:

• 12.6% of heterosexual students.

• 27.0% of students not sure of their sexual identity.

• 25.7% of GLB students.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

The Centers for Disease Control and Prevention released results from the first nationally representative study on health risk behaviors of gay, lesbian, and bisexual (GLB) high school students in August 2016.

These data were collected through the Youth Risk Behavior Survey (YRBS) questionnaire. The YRBS questionnaire was developed in 1990 as a way to monitor health-related behaviors that contribute to the leading causes of mortality and morbidity in youth and young adults. Areas covered by the survey include behaviors related to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, and physical activity. Data are collected every 2 years through national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th-12th grade students.

Selected questionnaire results

Sexual identity

• 88.8% of students identified as heterosexual.

• 6.0% identified as bisexual.

• 3.2% were not sure.

• 2.0% identified as gay or lesbian.

Sexual behaviors

• 48% had had sexual contact with the opposite sex only.

• 4.6% had sexual contact with both sexes.

• 1.7% had had sexual contact with the same sex only.

• 45.7% had no sexual contact.

Mental health

Percent of students who reported making a suicide plan in the 12 months preceding the survey:

• 11.9% of heterosexual students.

• 27.9% of students not sure of sexual identity.

• 38.2% of gay, lesbian, bisexual (GLB) students.

Percent of students who attempted suicide in the 12 months preceding the survey:

• 6.4% of heterosexual students.

• 13.7% of students not sure of sexual identity.

• 29.4% of GLB students.

Sexual Behaviors

First sex before the age of 13:

• 3.4% of heterosexual students.

• 8.8% of students not sure of their sexual identity.

• 7.3% of GLB students.

Drank alcohol or used drugs before last sex:

• 20.0% of heterosexual students.

• 44.5% of students not sure of their sexual identity.

• 22.4% of GLB students.

Tested for HIV:

• 9.3% of heterosexual students.

• 12.8% of students not sure of their sexual identity.

• 18.2% of GLB students.

Substance use

Currently smoking cigarettes daily:

• 1.9% of heterosexual students.

• 7.0% of students not sure of their sexual identity.

• 4.0% of GLB students.

Current alcohol use:

• 32.1% of heterosexual students.

• 34.6% of students not sure of their sexual identity.

• 40.5% of GLB students.

Current marijuana use:

• 20.7% of heterosexual students.

• 26.0% of students not sure of their sexual identity.

• 32.0% of GLB students.

Used hallucinogenic drugs (such as LSD, acid, PCP, angel dust, mescaline, or mushrooms):

• 5.5% of heterosexual students.

• 15.7% of students not sure of their sexual identity.

• 11.5% of GLB students.

Ever used heroin:

• 1.3% of heterosexual students.

• 9.3% of students not sure of their sexual identity.

• 6.0% of GLB students.

Ever took prescription drugs without a doctor’s prescription:

15.5% of heterosexual students.

24.3% of students not sure of their sexual identity.

27.5% of GLB students.

Physical Activity

Did not participate in at least 60 minutes of physical activity on at least 1 day in past week:

• 12.6% of heterosexual students.

• 27.0% of students not sure of their sexual identity.

• 25.7% of GLB students.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

The Centers for Disease Control and Prevention released results from the first nationally representative study on health risk behaviors of gay, lesbian, and bisexual (GLB) high school students in August 2016.

These data were collected through the Youth Risk Behavior Survey (YRBS) questionnaire. The YRBS questionnaire was developed in 1990 as a way to monitor health-related behaviors that contribute to the leading causes of mortality and morbidity in youth and young adults. Areas covered by the survey include behaviors related to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, and physical activity. Data are collected every 2 years through national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th-12th grade students.

Selected questionnaire results

Sexual identity

• 88.8% of students identified as heterosexual.

• 6.0% identified as bisexual.

• 3.2% were not sure.

• 2.0% identified as gay or lesbian.

Sexual behaviors

• 48% had had sexual contact with the opposite sex only.

• 4.6% had sexual contact with both sexes.

• 1.7% had had sexual contact with the same sex only.

• 45.7% had no sexual contact.

Mental health

Percent of students who reported making a suicide plan in the 12 months preceding the survey:

• 11.9% of heterosexual students.

• 27.9% of students not sure of sexual identity.

• 38.2% of gay, lesbian, bisexual (GLB) students.

Percent of students who attempted suicide in the 12 months preceding the survey:

• 6.4% of heterosexual students.

• 13.7% of students not sure of sexual identity.

• 29.4% of GLB students.

Sexual Behaviors

First sex before the age of 13:

• 3.4% of heterosexual students.

• 8.8% of students not sure of their sexual identity.

• 7.3% of GLB students.

Drank alcohol or used drugs before last sex:

• 20.0% of heterosexual students.

• 44.5% of students not sure of their sexual identity.

• 22.4% of GLB students.

Tested for HIV:

• 9.3% of heterosexual students.

• 12.8% of students not sure of their sexual identity.

• 18.2% of GLB students.

Substance use

Currently smoking cigarettes daily:

• 1.9% of heterosexual students.

• 7.0% of students not sure of their sexual identity.

• 4.0% of GLB students.

Current alcohol use:

• 32.1% of heterosexual students.

• 34.6% of students not sure of their sexual identity.

• 40.5% of GLB students.

Current marijuana use:

• 20.7% of heterosexual students.

• 26.0% of students not sure of their sexual identity.

• 32.0% of GLB students.

Used hallucinogenic drugs (such as LSD, acid, PCP, angel dust, mescaline, or mushrooms):

• 5.5% of heterosexual students.

• 15.7% of students not sure of their sexual identity.

• 11.5% of GLB students.

Ever used heroin:

• 1.3% of heterosexual students.

• 9.3% of students not sure of their sexual identity.

• 6.0% of GLB students.

Ever took prescription drugs without a doctor’s prescription:

15.5% of heterosexual students.

24.3% of students not sure of their sexual identity.

27.5% of GLB students.

Physical Activity

Did not participate in at least 60 minutes of physical activity on at least 1 day in past week:

• 12.6% of heterosexual students.

• 27.0% of students not sure of their sexual identity.

• 25.7% of GLB students.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.