Due to the epidemic of the acquired immunodeficiency syndrome, adolescent homosexuality has become one of the most critical issues of pediatrics and adolescent health care in the 1980s. However, the controversies surrounding the issue often discourage health professionals, educators, researchers, and the gay community alike from being involved in the care of young people struggling with the problems of sexual identity; the general lack of data regarding homosexual youths perpetuates the emotionalism of the subject. Our intent here is to provide practical information from the literature and from our own experience to pediatricians and other professionals who are interested in working with young gays and lesbians.
In the 1940s, Kinsey1 revolutionized concepts of sexual identity with the then startling observation that approximately 10% of American mates were predominantly homosexual, and nearly four times as many had homosexual experiences at some time in their lives. Subsequently, sexual orientation has come to be seen as a point on a continuum between absolute homosexuality and absolute heterosexuality, with most people railing on the wide spectrum between the two extremes. Other investigators have contributed to an appreciation that sexual orientation involves more than sexual behavior, but also includes the dimensions of sexual fantasy life, inner identity, and social role.2
While numerous studies of adult homosexuality and bisexuality followed Kinsey's report, understanding of adolescent sexuality has proceeded at a slower pace. To our knowledge, the first investigation involving gay adolescents was an exploration of juvenile male pros' titution conducted by Deisher and colleagues in 1969. 3 The authors described sexual, economic, psychological, and physical factors contributing to the phenomenon and recommended realistic preventative and rehabilitative efforts. The article was followed by an editorial in Peawirics4 that reflected the attitudes of the times;
The culture created by homosexuals reflects their own assertive characteristics, reflecting also their destructive interactions and adjustment in a society that disapproves of them because they are homosexuals. . . . Although the study and treatment of the sexual deviant is primarily the responsibility of psychoanalysts and psychiatrists, pediatricians may be significantly involved in the prevention of this developmental deviation.
The full extent of adolescent homosexual activity was not appreciated until 1973, when Sorenson5 reported that 11% of boys and 6% of girls between the ages of 13 and 19 had had at least one homosexual experience. Among the cohort of males age 16 to 19 years, 17% reported such activity. Yet, the percentage of adolescents who are predominantly homosexual in their orientation is still unknown, although estimates range as high as 10%. 6
Adolescent homosexual activity has frequently been dismissed as an experimentation with sexuality in a way that is comfortable to young persons who will eventually adopt a heterosexual identity. And, in studies such as Sorenson's, gay and lesbian teenagers who were not sexually active have been counted as heterosexual. During the 1970s, particular authors7 rejected a priori the possibility that a homosexual preference could be established during adolescence. In contrast, Roesler and Deisher8 published a pioneering investigation of youthful male homosexuality in 1972 demonstrating the occurrence of adolescent homosexuality and describing the "extreme emotional turmoil" of males acquiring a homosexual identity early in life.
The issue of the psychological normalcy or abnormality of homosexuals was hotly debated throughout the 1970s; and, in the face of considerable controversy, the American Psychiatric Association removed homosexuality per se from the DSM-II classification of mental disorders in 1973. In the following years, the gay rights movement, the women's movement, the increased visibility of gays and lesbians, and numerous legal and political battles have brought the issue of adult homosexuality to public scrutiny, while adolescent homosexuality remained a poorly understood entity. Only recently has the urgency of the AIDS epidemic forced attention to this volatile subject. This 1983 statement of policy from the American Academy of Pediatrics9 reflects a new interest and a noticeable change in perspective from the previously quoted editorial:
Teenagers, their parents, and community organizations may look to the pediatrician for clarification of the medical and social issues involved when the question or feet of adolescent homosexual practices arises. . . . The American Academy of Pediatrics recognizes the physician's responsibility to provide health care for homosexual adolescents and for those young people struggling with the problems of sexual expression.
DEHNITIONS OF ADOLESCENT HOMOSEXUALITY
Misunderstanding of the meaning of adolescent homosexuality frequently contributes to the emotionalism of the issue. Homosexuality is often erroneously associated with transvestism (cross-dressing), transsexualism (mismatching of sexual phenotype and psychological gender), and pedophilia (sexual attraction to children). These phenomena may occur among heterosexuals and homosexuals alike, and they bear no direct relation to sexual orientation per se.10 The most common misconception is that homosexuality strictly refers to sexual behaviors between persons of the same sex. This viewpoint neglects the affectional or emotional aspects of sexuality and may be misleading as well, since gay adolescents are frequently aware of their homosexual feelings long before they have sexual experiences. Both heterosexual and homosexual youths may engage in heterosexual and homosexual activity; adolescent sexual activity is often a poor indicator of ultimate sexual preference.11 Spitzer12 has provided the following practical definition of homosexuality, which can be applied to the care of adolescents: "Homosexuality is a persistent pattern of homosexual arousal, but also a persistent pattern of absent or weak heterosexual arousal." It is advisable to explore the meaning of homosexuality with clients who experience distress over the issue.
ACQUISITION OF A HOMOSEXUAL IDENTITY
Although the biologic and psychological determinants of sexual preference remain unclear,13 there is relatively more information regarding the process whereby an individual adopts and adapts to a homosexual identity. Simply stated, the acquisition of a homosexual identity is a long process that begins in early childhood and generally extends through adulthood. The process has been conceptualized as a progression through a number of developmental stages. On the basis of in-depth interviews with gay adults, Troiden14 has proposed that the sequence of events begins in childhood or early adolescence with an individual's recognition of diflerentness or apartness from peers. At that time, the young person is not aware of the underlying reasons for his or her sense of estrangement. The next stage involves the actual emergence of homosexual feelings or impulses, but these attractions are typically repressed, ignored, or dismissed as a passing phase. Saghir and colleagues'5 found that 77% of adult homosexual subjects had developed préadolescent homosexual attachments and 86% engaged in homosexual activity by age 15. Because of the persistence of these feelings over time, the individual eventually acknowledges a homosexual identity, first to himself and then to others. In their work with gay adolescents and young adults, Roesler and Deisher8 identified the mean age at the time of "coming out" as being 14 years. Coleman16 has described subsequent stages of "exploration" (during which gay and lesbian adolescents experiment with their sexuality and make their entry into the homosexual community) and "first relationships" (a time of yearning for more stable and committed relationships). According to Troiden's model, the final step in the process is "commitment," at which time the individual is satisfied with his or her sexual identity, unwilling to change it, and can devote energy to the formation of stable and intimate relationships.
Adolescents who are in the process of acquiring a homosexual identity may encounter serious obstacles on the road to "commitment" in the form of social isolation, prejudice, and discrimination. Martin17 describes their predicament:
Every child learns not only what is expected of the various social idenrities he or she is being raised to but also what groups society abhors. In adolescence, young homosexually oriented persons are raced with the growing awareness that they may be among the most despised. They are forced to deal with the possibility that their actual social identity contradicts most of the other social identities to which they believe they are entitled. As this realization becomes more pressing, they are faced with three possible choices: they can hide, they can attempt to change the stigma, or they can accept it.
Each of these possibilities is suboptimal. Adolescents who accept the negative images attached to a homosexual identity are at risk for incorporating them within their own repertoire of behaviors. For example, they may assume the affectations or the promiscuous lifestyles that they believe ate socially expected. Those who hide typically experience damaged self-esteem, distancing from family and peers, and self-conscious attempts to avoid disclosure. Finally, those who attempt to change the stigma race the possibilities of conflict with parents and school authorities, social ostracization, and even threats to their physical safety.
MAJOR CATEGORIES OF SEXUALLY RELATED ILLNESS IN HOMOSEXUAL MALES
The issue of adolescent homosexuality may arise in a wide variety of clinical situations. Although the epidemiology of sexually transmitted diseases (STDs) in the gay adolescent population is poorly understood, there is reason to suspect that these youths are at risk for a number of illnesses. Compared with heterosexual men, gay men experience higher rates of syphilis, gonorrhea, hepatitis, and other enteric diseases.18 Seventy-three percent of U.S. citizens with the acquired immunodeficiency syndrome report a history of homosexual contacts,19 and 22% to 65% of adult homosexual males demonstrate seropositivity to HTLV-III. 20 Lesbians, on the other hand, are unlikely to present to the physician with any STDs.21
As illustrated in the Table, the sexually related illnesses of male homosexuals have been grouped into four categories: "classic" venereal diseases, viral illnesses, the "gay bowel syndrome," and the acquired immunodeficiency syndrome. While the implications of these illnesses for gay adolescents have been discussed elsewhere,11 it is important to note here that a complete sexual history is a critical item in the evaluation of adolescents who present with exanthems and enanthems, lymphadenopathy, constitutional symptoms, and complaints that are referable to the gastrointestinal and the genitourinary tracts.
Aside from sexually transmitted diseases, the issue of adolescent homosexuality may surface around a number of psychosocial problems, including family conflict, school avoidance, substance use and abuse, running away, juvenile prostitution, attempted suicide, and other mental health problems. One Philadelphia agency serving adolescent sexual minority members reports that 50% of their clients have been involved in juvenile prostitution. Twenty-five percent are runaways and at least 25% are school phobic.22 In Roesler and Deisher's8 sample of gay males of age 16 through 19, 48% of subjects had consulted a psychiatrist on at least one occasion. Thirty-one percent admitted to a serious suicide attempt and half of these reported multiple attempts.
THE PATIENT INTERVIEW
Theories regarding the development of a homosexual identity have practical applications for clinicians. It is important to understand that young adolescents who are struggling with the issue of sexual identity may not have the prerequisite language or insight necessary to describe their sexual preferences or to articulate the conflicts that they experience. Moreover, when the question or possibility of a child's homosexuality is raised, it is seldom possible to resolve suspicions until the patient is emotionally prepared to do so.
Premature labeling of an adolescent's sexual identity is generally unnecessary and potentially damaging to the young person who may not have the resources needed to cope with the possibility of gay or lesbian identity. Even when the adolescent has a clear sense of his or her homosexual identity, she or he may be reluctant to discuss the issues, fearing breach of confidence or negative responses.
Conversation with teenagers regarding homosexuality or most other aspects of sexuality are best prefaced with an assurance of privacy and confidentiality. Since many adolescents are highly introspective and self-conscious, it is often helpful to provide an open and honest explanation for the particular Une of questioning. For instance, the sexual history-taking for a teenager with a urethral discharge may begin: "In order for me to give you the appropriate care for your medical problem, I need to ask you some questions about sex. These questions are routine, and your answers will be kept private." Questions should be simple, nontechnical, and reflect permission for frank discussion: "Many young people are sexually active. How about you? Do you understand what I mean by 'sexually active'?" Questions should move from general to more specific information: "Have you had sex with just one partner or more than one? Have you had sex with guys, girls, or both?" If a history of homosexual practices is elicited, a special attentiveness to medical and psychosocial ramifications is warranted: "Do you think of yourself as gay, bisexual, or heterosexual? Have you discussed your sexuality with your friends or parents? Do you have a 'steady' partner? Can you tell me more about him? Have you ever had V. D. or a sexually related illness? Do you get a regular check-up for these problems?" etc.
Pediatricians work with teenagers in a wide variety of settings, including traditional pediatrie clinics, community or hospital-based teen clinics, high schools, residential treatment or detention facilities, and STD clinics. It is important to consider the context of the clinical setting during the medical encounter. For example, it may be difficult and inappropriate to broach the issue of homosexuality in a busy pediatrie office with the patient's mother located just outside the examining room door. Even in other settings, itmaybe necessary to develop a rapport with adolescents gradually during the course of follow-up visits before discussions of sexuality are undertaken.
THE PHYSICAL EXAMINATION
A sensitive and thorough medical history lays the groundwork for an accurate physical examination. Relatively common physical findings such as lymphadenopathy or ecchymoses may take on new significance in light of a history of homosexual activity. Retrospective sexual history-taking often leads to awkward moments and should be avoided. Observations, such as the following, may be disturbing to any adolescent: "I notice that your glands are swollen. Are you, by any chance, homosexual?" Moreover, the physical examination is a poor substitute for a complete sexual history in obtaining information regarding sexual behavior. For example, the "patulous anus" is neither a specific nor sensitive physical sign of homosexuality due to the wide variability of sexual practices among gay males.
The appropriate use of laboratory testing in a homosexual population is an important and controversial issue. While the growing popularity of "safe" sexual practices may change patterns of STDs, routine screening for infection remains essential at the present time. Given the frequency of silent gonococcal and treponemal infections, periodic examination of sexually active gay males has been advocated at time intervals ranging from every month to every year, as determined by sexual behavior risk factors.23 Testing includes syphilis sérologies and oral and rectal gonorrhea cultures. Routine urethral cultures may have low yield in a homosexual population due to the relatively low prevalence of the hypoxanthine-guanine-uracil requiring strains that cause asymptomatic infection. In addition, males who are susceptible to hepatitis B, as determined by appropriate serologie tests, should be immunized. Even in the absence of heterosexual intercourse, lesbians require periodic Pap smears for the early detection of cervical cancer.21
Considerable controversy surrounds HTLV-III antibody testing. Although it is the hope that such testing would provide healthy individuals in high-risk groups with an incentive to modify sexual practices, dissenters argue that persons tested are at risk for discriminatory practices, infringement of their civil rights, and loss of medical liability coverage. For adolescents there are additional concerns regarding the response of the educational system to infected students. The intensity of these concerns has grown in the wake of the decision on the part of various state health departments to eliminate anonymous testing and to enact sexual contact tracing for persons who are positive.
Requests for testing may come from either heterosexual or homosexual teenagers. Adolescents who are less aware of the social issues or who have a less developed future time perspective may have difficulty appreciating its implications. Health professionals can be helpful by objectively presenting the pros and cons of testing and by stimulating young people to consider the concrete applications of these test results to their own lives.
In addition to providing medical care to homosexual youths, pediatricians can play an especially important role in anticipatory guidance. In 1986, education about sexual practices is the only tool available to prevent the spread of AIDS. The principles of "safe" sexual practices are likely to benefit heterosexual and homosexual adolescents alike. These practices include limiting the number of sexual partners, use of condoms during intercourse, avoiding the exchange of body fluids during sexual activity, and the promotion of alternative expressions of intimacy, including affectionate touching and mutual masturbation. Widescale promotion of such practices may not only reduce the incidence of HTLV-III infections but also impact upon the problems of teen pregnancy, infectious mononucleosis, herpes simplex infections, and a number of other more treatable STDs.
Although such patient education may at first glance appear radical and unrealistic, the success of safe sex campaigns in modifying the sexual behaviors in the gay community is evidence of its realistic potential.24 During the 1960s and 1970s, changing sexual mores, contraceptive technology, and a number of other sociologie factors contributed to changing patterns of sexually transmitted diseases in the 1980s. There is a growing awareness that major social change is once again necessary to confront the problems of potentially fatal infectious diseases, premature parenthood, and infertility.
Aside from the medical issues surrounding adolescent homosexuality, physicians may be called upon by teenagers, parents, and educators to provide advice on the psychosocial aspects of adolescent homosexuality. While many pediatricians would defer to mental health professionals in these areas, a general knowledge of treatment modalities is helpful in selecting consultants. Given the variability of attitudes and approaches to the issue of adolescent homosexuality, exploration of the consultant's perspective is essential prior to making referral. The reader is referred to Coleman's25 review of therapeutic modalities for a more in-depth discussion; but, in general, it may be said that most approaches fall into two categories: attempts to change an individual's homosexual behaviors and attempts to help the individual adjust to a homosexual identity. The former includes behavioral and/or psychoanalytic therapy devoted to extinguishing homosexual impulses and encouraging heterosexual activity. Within these broad categories, multiple treatment strategies have been employed, including modifying sexual fantasies, aversive conditioning with electric shock, nausea- indue ing drugs or imagery, desensitization to heterosexual anxiety, and sexual counseling. These approaches are highly controversial and their effectiveness, ethicality (particularly as applied to an adolescent population), and complications have been questioned.
Attempts to help the individual adjust to a homosexual identity include individual, family, and group therapy, assertiveness training, support groups for teenagers and for their families, and special educational, job-training, mental health, and chemical dependency treatment programs for gay and lesbian adolescents. Although these approaches hold promise, there is a clear need for an investigation of the impact of such programs on the adolescent's outcome.
In the final analysis, the care of gay and lesbian adolescents is an important issue that unfortunately rests less heavily in scientific feet than in the personal discretion of the provider. Pediatricians are strongly urged to consider carefully how their own attitudes impact on their care of families, to promote discussion of the issues within their communities, to support and to participate in research in the area of adolescent sexuality, and to provide education and care to all children and adolescents, regardless of sexual preference.
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MAJOR CATEGORIES OF SEXUALLY RELATED ILLNESS IN HOMOSEXUAL MALES