Gay, lesbian, bisexual, and transgendered individuals have always been present in human society.1,2 References to same-sex couples and activity have been noted as far back as 600 B.C. on ancient Japanese and Chinese pottery. Ancient Greek and Roman art is full of depictions of same-sex couples; some scholars believe that Alexander the Great was gay.3
The history of the modern gay, lesbian, bisexual, and transgendered (GLBT) movement emerged with the Stonewall Inn riots in New York City in June 1969, which focused on the attainment of equal rights and societal acceptance for GLBT individuals. The fight for marriage equality is currently the most prominent issue; one that has been endorsed by President Obama. Despite the attainment of equal rights in certain countries, homosexuality is still seen as a perversion by certain groups, and the death penalty for homosexuality is still present in several African and Middle Eastern countries.
“Sexual orientation” refers to an individual’s pattern of physical and emotional attractions to others.2 “Homosexuality” is a persistent sexual and emotional attraction to members of one’s own gender.2 Persons who are attracted to members of the opposite sex are known as “heterosexuals” or “straight.” “Gay” can be an umbrella term for both homosexual men and women, “lesbian” refers to women. “Bisexuals” are those individuals who are attracted to both men and women. “Gender identity” refers to an individual’s innate sense of being male or female. “Transgender” is an encompassing term that includes “transsexual,” “gender non-conforming,” “gender queer,” and other trans-identities. “Queer” is sometimes used by youth to refer either to their gender identify or sexual orientation; it is often used by those who wish to avoid labels such as “gay” or “straight.” Typically, the term “transsexual” refers to individuals who feel that their biologic sex and their gender identity are not in agreement. It makes no inference regarding biological sex status, sexual orientation, or surgical status.
“Homophobia” refers to an irrational fear, prejudice, and hatred of gay individuals.4 The term “MSM” or “men who have sex with men,” is generally considered a research term and reflects sexual behavior, not orientation or identity. “WSW” refers to women who have sex with other women. “Heterosexism” is the belief that heterosexuality is the superior sexual orientation and does not value alternative sexual identities.
There appear to be several domains that make up an individual’s overall sexual identity. The primary domains are: sexual orientation, sexual behavior, gender identity/expression, sexual attraction, and biologic sex (see Figure 1). Kinsey,5 in his work from the 1940s, was the first to document that sexual orientation exists along a continuum, but all of these domains are variable. For example, in terms of sexual orientation, a person may identify as 100% gay, 100% straight, or somewhere in between (bisexual) in varying proportions. Frequently, these scales can be static, but may change depending on various factors. Where an individual falls on any given continuum may change with time and circumstances.
Figure 1. Paradigm of sexuality.Image courtesy of Physicians for Reproductive Choice and Health.Reprinted with permission.
Determinants of Sexual Orientation
The determinants of sexual orientation are not known. It is thought to be due to a combination of genetics, hormones, and environmental factors.2,6 It is also important to note that sexual orientation is not a choice made by the gay individual, and is not due to parenting, sexual abuse, or other adverse life events. Sexual behavior, but not orientation, may be influenced by these factors.2,6 Sexual orientation and gender identity are developmental processes that are not guided by conscious decisions. Gender identity is usually set by age 3 or 4 years,7 and sexual orientation around age 9 or 10 years.8
Data on the prevalence of GLBT youth is sparse. There are few national health surveys that ask about sexual orientation and no national survey has questions about gender identity. According to the Youth Risk Behavior Survey (YRBS) data from Minnesota and Vermont, about 1% of 9th graders identify as “gay/ lesbian,” 10% as “unsure,” and 89% as “straight.”9 This can be interpreted as uncertainty about sexual orientation that diminishes with age; as one’s self-awareness increases, identification as either gay or straight increases.
From surveys of adults, it is estimated that 3.5%10 of the US population identifies as gay or lesbian. These findings suggest an unfolding sexual identity that is developmentally based. The average age to disclose one’s sexual orientation (“to come out”) is age 16 years,11 but many adults will recall retrospectively that they knew they were different from their straight peers as early as age 9 or 10 years.11,12
Sexual orientation is not necessarily linked to any specific sexual behavior. Sexual experimentation with same-sex partners occurs among youth who later identify as both straight and gay. This affirms that sexual identity is an internal development and not a reaction to a sexual behavior event.
Health Disparities in the GLBT Population
According to the American Academy of Pediatrics (AAP), GLBT people have an increased risk of contracting sexually transmitted diseases, including HIV.2 They smoke more, drink more, and are more likely to have used illegal drugs recently.13,14 Their rates of sexually transmitted diseases (STDs), including gonorrhea, syphilis, and HIV, are higher than their straight peers.15 They also are more likely to have multiple partners.14 Suicide and suicide attempts are two to seven times greater in GLBT youth.13,16 GLBT youth are at greater risk for trauma, sexual assault,17 and eating disorders.18 Although research on GLBT youth is often focused on males, when young queer women are included, findings indicate a high incidence of unintended pregnancy and unsafe heterosexual sex.19
The Centers for Disease Control and Prevention (CDC) surveillance data from 2009 indicates that adolescent acquisition of HIV is increasing.20 Although the largest number of cases of HIV is seen in MSM aged 25 to 34 years old, the largest proportional increase (53%) occurred among MSM aged 13 to 24 years old.20 Of those youth who contract HIV, the majority of cases are in minority youth.20 Reasons for increased risk of HIV include early sexual debut,13 older first partners, poor condom use, increased numbers of partners, partners who are at higher risk of having HIV, and increased use of illicit substances.13,14
Standard disease rates for illness such as diabetes, cancer, and heart disease appear to be similar between GLBT individuals and their straight peers.20 However, transgender and gender non-conforming people delayed evaluation by a medical professional when they were sick or injured for fear of being discriminated against, thus increasing the odds of a poor outcome for a medical illness.22 There is no biologic difference between straight and gay youth; therefore the medical disparities of GLBT youth are attributable to the stressors of homophobia, bullying, and harassment.23
GLBT Mental Health
Living within a heterosexist society uniquely shapes the experiences of GLBT youth. In addition to the “normal” strains of adolescence, GLBT youth must cope with stigma, discrimination, and heterosexism, all of which have been consistently identified as stressors for sexual minority individuals.15 Most of the mental health difficulties that GLBT youth face can be traced to homophobia.20
There are two types of homophobia; internal and external. External homophobia is when outside persons are hateful and prejudiced toward someone who is gay. Externalized homophobia may come from strangers, family members, schools, classmates, or churches. Internal homophobia is when the youth has mentally internalized that hatred. This can lead to feelings of low self-worth, depression, and low self-esteem.15,24 Youth who experience both internalized and externalized homophobia may attempt to cope through self-medicating with drugs and alcohol.15 Youth may begin to seek friendships with others who are more accepting of their homosexual identity in locations such as bars and clubs frequented by other GLBTs.15
When GLBT youth look for acceptance and companionship in bars and clubs, they are increasingly vulnerable to exposure to substance use, as well as sexual victimization. HIV and other STDs may be transmitted to youth who are not well-equipped to ask about HIV status, are often powerless to insist on condom use, and may be too intoxicated with drugs and alcohol to avoid partaking in risky behavior.
Internalized homophobia may impact a GLBT youth’s ability to effectively prevent pregnancy and STIs. Both forms of homophobia may lead to poor mental health by inducing additional chronic stressors in an already stressed adolescent. Depression, suicidal ideation/attempts and bad decision-making regarding health behaviors can be a result of poor mental health.8
Reparative therapy, an ineffective and discredited form of psychotherapy aimed at eliminating homosexual desires, has been suggested to provide a “cure” for homosexuality. All legitimate psychological groups have denounced reparative therapy as ineffective.25 California state law banned the use of reparative therapy in youth aged younger than 18 years as of Oct. 1, 2012.
Instead of attempting to alter GLBT youth, energy may be better spent on creating a supportive and safe environment, which has been shown not only to promote self-esteem, but cultivate other more life-affirming habits. For example, a supportive social environment for GLBT youth is significantly associated with reduced tobacco use.26 Data from the Massachusetts YRBS indicates that when provided with GLBT-sensitive HIV instruction in schools, the sexual risk profile of GLBT youth can improve. It is associated with fewer sexual partners and less pre-sex substance use.27 Counseling should be provided to youth (and their parents) who are upset about their homosexual identity, and the goal is for acceptance, not change of the sexual orientation of the youth.
The physical and mental health of GLBT youth should not be viewed only in the context of self-defeating and compromising behaviors. Although many are disproportionately affected by risk behaviors such as substance use and high-risk sexual activity, most mature into healthy adults who lead productive lives. Youth who overcome the stress created by societal homophobia develop and possess remarkable strength and determination. Youth should not have to overcome this alone. Pediatricians have a unique opportunity to provide medical care in a safe and supportive environment for GLBT youth.
Care Of GLBT Youth
According to the American Medical Association (AMA), medical schools need to more thoroughly teach about the health issues faced by GLBT individuals.28 Only 8% of 176 medical schools’ Deans of Medical Education involved in a study taught all 16 health issues identified by practitioners as being critical to the health of GLBT individuals.28 These topics include sex reassignment surgery, inaccessibility of health care, and safer sex. Few schools spend more than 5 hours discussing these topics in the classroom, and one-third of schools did not discuss them at all.28 According to a study in 1998, 22% of physicians believed it was acceptable to assume heterosexuality unless told otherwise, and 68% of pediatricians do not include a sexual history at any age.29
Providers and staff should be able to elicit an appropriate sexual history and be open to the answers provided by youth. Often, youth will not raise the issue directly, but will see if the clinician does. If the provider makes it a habit to ask all adolescents about their romantic and sexual partners, using non-gendered pronouns, it normalizes the question and acknowledges that there are a range of sexual orientations, behaviors, and gender identities. Thus, the information that is elicited will be accurate and clinical decisions will be relevant. If questions are asked appropriately, youth will feel welcomed and will feel heard, thereby opening the door to further communication between doctor and patient.
Primary care providers should feel comfortable taking care of GLBT youth. Physicians can ensure that their offices are GLBT friendly with affirming posters and signs around the clinical space. The use of lab coat pins with GLBT symbols, eg, the inverted pink triangle or the rainbow flag, are subtle ways that clinicians can communicate to youth that they are “gay-friendly” and open to honest communication about GLBT issues. Health education posters that promote open and honest communication are helpful. National and local GLBT centers also have age-appropriate educational materials for a pediatric office.
In order to improve outcomes, staff should have GLBT issue awareness training so they may competently and appropriately interact with and assist the GLBT youth population. It is critically important to acknowledge that many GLBT youth are also members of ethnic minority groups. Practitioners must be aware of how race and sexuality intersect in their patient’s identity and how GLBT youth are viewed within the patient’s particular ethnic group.
The conversation between youth and provider may be the first time that the adolescent has directly been asked about sexual attraction, orientation, and behavior. Medical providers must be able to assess issues around safety of the youth, depression, and familial acceptance.29 It is important to inquire as to whom the youth has disclosed his/her sexual and gender identity. A clinician should be capable of assisting the youth with disclosure to family, and to facilitate communication with parents (see Sidebar). Frequently, close friends are the first to know, followed by the immediate, and then extended family.12 Youth may or may not reach a point when they are comfortable disclosing their sexual orientation to others such as teachers, clergy, and co-workers. The “coming-out” process is individual for each person. Referrals to local mental health professionals are important. Providers must also be aware of supportive resources for family members (eg, Parents and Friends or Lesbians and Gays) or other local individual or group counselors.
Tips for Discussing Sexual Issues with Adolescents
Do not assume heterosexuality when dealing with teenagers. The best way to do this is by using gender neutral and/or inclusive pronouns.
If an adolescent discloses a same-sex attraction or identity, do not assume that he or she is not also experimenting sexually with the opposite sex.
If a patient discloses heterosexuality, do not assume he or she is not also experimenting with same-sex partners.
For adolescents, and especially GLBT adolescents, who often spend their lives feeling “unheard,” listening to their issues and concerns takes on paramount importance.
Ask specific questions when talking to any teen (GLBT or heterosexual). Asking a teen whether he or she is “sexually active” gets a very different answer than “When was the last time you had sex?” Ask the teen to define what “sex” means for him or her. Asking if a teen is dating has almost no correlation to whether that teen is having sex. These have VERY different meanings.
Do not only talk about sex and safe sex. Adolescents are much more complex than their sexual lives. The use of questionnaire such as the HEADSS (Home, Education, Activities, Drugs, Sex and Suicide) Survey can elicit a wealth of information about a youth that is much broader and richer than a narrow focus on sex and sexuality.
Be supportive. If helping a GLBT teen disclose his or her sexuality to the family, facilitate clear communication in a safe environment and have GLBT resources available, such as the contact information for a counselor versed in GLBT issues.
GLBT = gay, lesbian, bisexual, and transgendered.
Preventive Health for Glbt Youth
Overall, GLBT youth have the same preventive health care needs as heterosexual adolescents. Practitioners should be familiar with the preventive recommendations of the American Medical Association’s Guidelines for Adolescent Preventive Services (GAPS) and the AAP’s Bright Futures. Particular attention should be paid to health guidance around physical growth, psychosocial, and psychosexual development. Immunizations for hepatitis A and B are important as well as vaccines for HPV; this vaccination is recommended for both boys and girls regardless of sexual orientation or activity. At all ages, adolescent youth should be engaged in active decision-making about their health care.
Reproductive health is an important aspect of providing medical care to all youth, and especially GLBT youth. Many youth may experiment with sexual activity with members of the opposite sex. Some research has shown that GLB youth are more likely to participate in an unplanned teen pregnancy.19 Honest and frank discussions about condoms, barrier methods, and abstinence are important to prevent the spread of disease. GLBT adolescents should be aware of hormonal birth control, including accessing emergency contraception. Other issues around reproductive care include advice on pre- and post-exposure HIV care and prevention of sexual exploitation.
Awareness of CDC recommendations for STD/HIV testing is important. STD/HIV screening is recommended for all adolescents and should be based on the specific behaviors of the youth being evaluated. Homosexual youth may identify as gay prior to sexual relations or after only limited sexual experiences. Clinicians must strive to not pathologize a youth’s sexual life by linking sexual orientation and behavior to STDs, as this can give the message that the youth is “dirty” or “diseased” because of his or her sexual orientation.
Current CDC guidelines for STD screening of MSM include annual HIV serology, annual syphilis serology, annual screening for genital chlamydia, and gonorrhea testing.30 Rectal and pharyngeal STD swabs are recommended, but these authors believe it is better to ask the youth about specific behaviors in which they engage before ordering those specific tests. Serology for hepatitis A, B, and C should be considered. More frequent screening for STDs also should be considered if the youth reports having multiple partners, older partners, frequent unprotected sex, or a substance use habit, especially with substances such as crystal methamphetamine or injection drug use.
Emerging issues for discussion include recommendations regarding anal cytology (anal pap smears), HPV testing, HSV screening, and the use of Nucleic Acid Amplified Tests (NAATS) testing for chlamydia and gonorrhea in non-genital sites.
For women who have sex with other women, the CDC recommendations are simpler and state that all females should be advised to have a routine Pap smear at age 21 years. STD testing for trichomonas, syphilis, chlamydia, gonorrhea, and HPV should be based “according to risk factors.”29 While women who have only had sex with other women are unlikely to have a bacterial STD,30 studies have indicated that many lesbian-identified women have had heterosexual sex at some point in their lives. There are no unique gynecologic problems that are more common in lesbians than in bisexual or heterosexual women.8 Certainly, infections such as trichomonas, HPV, and bacterial vaginosis can be passed from one woman to another.
GLBT Mental Health Care and Safety
Issues around depression, eating disorders, and safety must also be explored and addressed in this population. Practitioners should be aware that GLBT youth might be victims of and perpetuators of dating violence.32 This is very important, given the evidence that gay and lesbian youth are often in sexual relationships with older adults and not with other youth of the same age. Locations such as school, home, and houses of worship are traditionally thought of as “safe spaces” for teens; however, GLBT youth may find that these are not safe for them, and many youth report feeling unsafe at school for a variety of reasons such as gender expression, sexual orientation, and even religious affiliation.24 This can have ripple effects such as higher absenteeism in school and lower grade point averages. Some youth have been ejected from their homes due to their sexual orientation; it is estimated that up to 25% to 40% of homeless youth are gay or lesbian.16
GLBT youth deserve the same high-quality medical care that all teens deserve. In most ways, they are just like other adolescents. Coming out is a unique developmental milestone for GLBT youth; there is no analogy in the heterosexual world. Awareness about the experiences of GLBT youth has increased significantly over the past several years as homosexuality has become more widely acknowledged and accepted by society.
As awareness of suicides by GLBT adolescents and young adults have increased, it has become clear that the needs of GLBT adolescents are not being met. Primary care providers and pediatricians have a unique opportunity to provide a safe, compassionate, and accepting space for GLBT youth and adolescents.
- Friedman RC, Downey JI. Homosexulaity. N Engl J Med. 1994;331(14): 923–930. doi:10.1056/NEJM199410063311407 [CrossRef]
- Frankowski BLAmerican Academy of Pediatrics Committee on Adolescence. Sexual orientation and adolescents. Pediatrics. 2004;113(6):1827–1832. doi:10.1542/peds.113.6.1827 [CrossRef]
- Ogden D. Alexander’s sex life. In: Heckel A, Heckel W, Tritle L (eds). Alexander the Great: A New History. Hoboken, NJ: Wiley-Blackwell; 2011.
- Weinberg G. Society and the Health Homosexual. New York, NY; St Martins Press; 1972.
- Kinsey AC., Pomeroy WD., Martin CE. Sexual behavior in the human male. Philadelphia, PA: WB Saunders; 1948.
- Savin-Williams RC. Theoretical perspectives accounting for adolescent homosexuality. J Adolesc Health Care. 1988;9(2):95–104. doi:10.1016/0197-0070(88)90055-1 [CrossRef]
- Dalton RF, Forman M, Muller B. Growth and development: psychologic treatment of children and adolescents. In: Behrman RF (ed). Nelson Textbook of Pediatrics. Philadelphia, PA. WB Saunders; 1992:69.
- Ryan C, Futterman D. Lesbian and Gay Youth Care and Counseling: The First Comprehensive Guide to Health and Mental Health Care. New York, NY: Columbia University Press; 1998.
- Remafedi G, Resnick M., Blum R., Harris L.Demography of sexual orientation in adolescents. Pediatrics. 1992;89(4 pt 2):714–721.
- Gates GJ. LGBT identity: a demographers’ perspective. Loyola of Los Angeles Law Review. 2012;45(3):693.
- Grov C, Bimbi DS, Nanin JE, Parsons JT.Race, ethnicity, gender and generational factors associated with the coming-out process among lesbian, gay and bisexual individuals. J Sex Res. 2006:43(2):115–121. doi:10.1080/00224490609552306 [CrossRef]
- Riley BH.GLB adolescents “coming out”. J Child Adolesc Psychiatr Nurs. 2010;23(1):3–10. doi:10.1111/j.1744-6171.2009.00210.x [CrossRef]
- Garofalo R, Wolf RC, Kessel S, Palfrey SJ, DuRant RH. The association between health risk behaviours and sexual orientation among a school-based sample of adolescents. Pediatrics. 1998;101(5):895–902. doi:10.1542/peds.101.5.895 [CrossRef]
- Rhodes SD, McCoy T, Hergenrather KC, Omli MR, Durant RH. Exploring the health behavior disparities of gay men in the US: comparing gay male university students to their straight peers. J LGBT Health Res. 2007;3(1):15–23. doi:10.1300/J463v03n01_03 [CrossRef]
- Valleroy LA, MacKellar DA, Karon JM, et al. HIV prevalence and associated risks in young men who have sex with men. JAMA. 2000;284(2):198–204. doi:10.1001/jama.284.2.198 [CrossRef]
- Savin-Williams RC. Verbal and physical abuse as stressors in the lives of lesbian, gay male and bisexual youth: associations with school problems, running away, substance abuse, prostitution and sucide. J Consult Clin Psychol. 1994;62(2):261–269. doi:10.1037/0022-006X.62.2.261 [CrossRef]
- Duncan DF. Prevalence of sexual assault victimization among heterosexual and gay/lesbian university students. Psychol Rep. 1990;66(1):65–66. doi:10.2466/pr0.19126.96.36.199 [CrossRef]
- Siever MD. Sexual orientation and gender as factors in socioculurally acquired vulnerability to body dissatisfaction and eating disorders. J Consult Clin Psychol. 1994;62(2):252–260. doi:10.1037/0022-006X.62.2.252 [CrossRef]
- Saewyc EM., Bearinger L, Blum RW, Resnick MDSexual intercourse, abuse and pregnancy among adolescent women: does sexual orientation make a difference?Fam Plann Perspect. 1999;31(3):127–131 doi:10.2307/2991695 [CrossRef]
- Centers for Disease Control and Prevention. HIV/AIDS Surveillance Update. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention; 2009.
- Conron KJ, Mimiaga MJ, Landers SJ. A population-based study of sexual orientation identity and gender differences in adult health. Am J Public Health. 2010;100(10):1953–1960. doi:10.2105/AJPH.2009.174169 [CrossRef]
- McKay B. Lesbian, Gay, Bisexual, and Transgender Health Issues, Disparities, and Information Resources. Med Ref Serv Q. 2011;30(4): 393–401. doi:10.1080/02763869.2011.608971 [CrossRef]
- Mays VM, Cochran SD. Mental health correlates of perceived discrimination among lesbian, gay and bisexual adults in the United States. Am J Pub Health. 2001;91(11):1869–1876. doi:10.2105/AJPH.91.11.1869 [CrossRef]
- Gay, Lesbian and Straight Education Network. The 2003 National School Climate Survey; The School Related Experiences of Our Nation’s Lesbian, Gay and Bisexual and Transgender Youth. New York, NY: GLSEN; 2004.
- Hein LC, Matthews A. Reparative therapy: the adolescent, the psych nurse, and the issues. J Child Adolesc Psychiatr Nurs. 2010; 23(1):29–35. doi:10.1111/j.1744-6171.2009.00214.x [CrossRef]
- Hatzenbuehler ML, Wieringa NF, Keyes KM. Community-level determinants of tobacco use disparities in lesbian, gay and bisexual youth. Arch Pediatr Adolesc Med. 2011;165(6):527–532. doi:10.1001/archpediatrics.2011.64 [CrossRef]
- Goodenow C, Szalacha L, Westheimer K. School support groups and other school factors, and the safety of sexual minority adolescents. Psychol Schools. 2006;43(5):573–589. doi:10.1002/pits.20173 [CrossRef]
- Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306(9):971–977. doi:10.1001/jama.2011.1255 [CrossRef]
- East J, El Rayess F. Pediatrician’s approach to the healthcare of lesbian, gay and bisexual youth. J Adolesc Health. 1998;23(4):191–193 doi:10.1016/S1054-139X(97)00164-X [CrossRef]
- Center for Disease Control. Sexually Transmitted Diseases Treatment Guidelines. Atlanta, GA. 2006.
- Bidwell RJ. Sexual orientation and gender identity. In: Friedman SN, Fisher M, Schonberg SK (eds). Comprehensive Adolescent Health Care. St. Louis, MO: Quality Medical Publishing; 1992.
- Pathela P, Schillinger JA. Sexual behaviors and sexual violence: adolescents with opposite-, same-, or both-sex partners. Pediatrics. 2010;126(5):879–886. doi:10.1542/peds.2010-0396 [CrossRef]
- Physicians for Reproductive Choice and Health. Adolescent Reproductive and Sexual Health Educational Project. New York, NY: 2012. Available at: www.prch.org/arshepdownloads. Accessed Jan. 11, 2013.