Optimizing primary care for LGBTQ youth

Foundations of sexual and gender identity

In order to understand sexual and gender identity development, one needs to distinguish between the following constructs: sexual orientation, sexual behavior, and gender or gender identity.

Sexual behavior refers to the way one chooses to express one's sexual feelings. Sexual behavior often does not correlate with sexual orientation, especially among adolescents.² In other words, heterosexually identified youth may have same-gender sexual experiences, and homosexually identified youth may have opposite-gender sexual experiences.

Gender identity is a personal and culturally defined construct based upon one's perception of being male or female. Much like sexual orientation, gender identity can occur across a wide continuum, and its complexity is not necessarily well captured as a binary structure. Transgender youth, for example, are individuals whose gender identity is discordant to some extent with their biologically or anatomically defined sex assigned at birth. Although a person may be born anatomically female, they may have a male gender identity (ie, female-to-male transgender individual).

But just how prevalent are LGBTQ youth? Challenges of the "coming out" process and a sundry of other factors make it difficult to obtain accurate estimates of this population. Studies have varied in their prevalence of homosexuality ranging from 2% to 10%, although studies in adults report closer to 10% may identify as lesbian, gay, or bisexual (LGB).³ This means that pediatricians will regularly encounter sexual minority youth in their clinical practice, although not all of these patients will have necessarily disclosed their sexual orientation or gender identity.

Data from one adolescent health survey suggests that the number of youth who self-identify as LGB increases with age, and that less than one third of youth who report same-sex sexual experiences will actually identify as LGB.² These data underscore the distinction between sexual orientation and sexual behavior, and highlight that sexual identity development is a dynamic process during which same-sex sexual experiences may be a norm.