Supporting the LGBTQ+ patient

Sexual minority and gender-diverse (SMGD) youth experience significant health and psychosocial disparities compared with their heterosexual and cisgender peers. Risk for poor health and social outcomes is incrementally higher among SMGD youth, but not universally so. Pediatricians, adolescent medicine physicians, and other youth providers can play a crucial role in mitigating this risk by supporting SMGD youth and their families and promoting resilience through inclusive and clinically, culturally competent care.

Sexual orientation encompasses sexual identity, attraction, and behavior. Gender identity refers to one’s internal sense of being male, female, or another gender identity. Sexual minority youth are individuals who identify as lesbian, gay, bisexual, or another nonheterosexual identity (eg, pansexual, same-gender loving), have same-sex attractions, engage in same-sex sexual behavior, or may be questioning their sexual orientation. Gender-diverse youth are individuals who identify as transgender; have a gender identity that differs from their sex assigned at birth; may be questioning their gender identity; or identify as agender, fluid, or nonbinary.

Sexual orientation and gender identity (SOGI) data are not routinely collected in the US Census or recorded in vital statistics; how- ever, national surveillance and polling data suggest increasing trends in the prevalence of SMGD youth and adults. Data from the Youth Risk Behavior Survey (YRBS)—a biennial survey of high school students—suggests the prevalence of sexual minority adolescents aged 13 to 17 years increased from 11.2% in 2015 to 15.6% in 2019, with adolescent respondents identifying as gay or lesbian increasing from 2.0% to 2.5%; bisexual, from 6.0% to 8.7%; and unsure, from 3.2% to 4.5%.¹ The YRBS collected data on gender identity for the first time during the 2017 wave of data collection in which 1.8% of adolescent respondents identified as transgender²—a prevalence more than double the prior estimates of 0.7% prevalence among adolescents aged 13 to 17 years.³ Another 1.6% reported being unsure of their gender identity.² The Gallup Poll, a telephone survey of a random sample of adults aged 18 and older, has similarly shown an increasing percentage of adults who identify as lesbian, gay, bisexual, or transgender (LGBT), from 3.5% in 2012 to 5.6% in 2020.⁴ In 2020, the question about LGBT identity was changed to allow respondents to specifically designate transgender identity in addition to lesbian, gay, or bisexual identity, which produced the following population prevalence estimates—3.1% bisexual, 1.4% gay, 0.7% lesbian, and 0.6% transgender.⁴ Whereas the Gallup Poll is limited to adults, the rise in reported LGBT identity was driven by increasing prevalence among younger age cohorts; 9.1% of millennials (born be- tween 1981 and 1996) and 15.9% of Generation Z who are 18 years and older (born between 1997-2002), identify as LGBT, suggesting these increasing trends are mirrored and potentially higher in adolescents.⁴

Identity development is one of the primary tasks of adolescence and includes development of one’s self- concept and social identity—how you fit into society and among social groups that share characteristics important to your self-concept (eg, race, ethnicity, culture, religiosity).^5,6 The formation of sexual and gender identity is an important component of identity development. Sexual identity formation theory suggests that identity occurs in stages as people try to align identity, behavior, and attraction and includes identity formation (ie, awareness, exploration, questioning sexuality) emerging in early adolescence followed by integration of sexual identity into one’s self-concept and disclosing to others (coming out) in middle to late adolescence.^7,8 This approach suggests a linear progression; however, others have suggested that sexual identity formation is nonlinear, fluid, and interconnected with lived experiences and other social identities, including racial/ethnic identities.^9,10 Gender identity typically develops in early childhood for cisgender as well as transgender and other gender-diverse youth; however, gender identity development also occurs in the context of social norms, biases, and familial and cultural expectations and can be a dynamic and evolving process from childhood into adolescence and adulthood.¹¹

Children and adolescents may present differently based on where they are in their gender or sexual identity development and on their exposures to anti-LGBT stigma and discrimination. They may present in a period of self-discovery or exploration; a period of questioning, confusion, or internal conflict; at a stage where they have fully realized and integrated their identity; or anywhere along this spectrum. At any and all of these stages, it is critical that pediatric and adolescent medicine providers meet and affirm patients where they are with reassurances that it is “entirely acceptable to be whoever you are” and explain that variations in sexual orientation and gender identity are normal aspects of human diversity. This approach is particularly important for youth who have experienced anti-LGBT stigma. The National Academies 2020 report “Understanding the Well-being of LGBTQI+ Populations”¹² notes the following:

“Early life course exposure to discrimination and stigma based on sexual orientation, gender identity, or intersex status can have lifelong consequences [...and] can set trajectories of health and well-being into motion that may be exacerbated by subsequent exposures to discrimination or interrupted by subsequent exposures to protective factors.”

Providers thus have the opportunity in their care of SMGD youth to interrupt or exacerbate the negative effects of the homophobia, transphobia, and heterosexism that many SMGD face. Unfortunately, some SMGD youth experience stigma, discrimination, and rejection in the health care setting. The Human Rights Campaign’s survey of over 10,000 LGBT-identified youth aged 13 to 17 years showed that 67% of LGB and 61% of transgender youth described not disclosing their sexual orientation or gender identity to their health care provider and that 80% of LGBT youth who identified as racial/ethnic minorities further described experiences of racial discrimination in health care settings.¹³ SMGD youth who have delayed dis- closure of their sexual orientation or gender identity have described dis- crimination, denial, and substandard care as a result of their sexual orientation or gender identity.¹⁴ Such experiences can also result in delayed medical care and poor access to treatment^15,16 and exacerbate rather than interrupt SMGD youths’ disproportionate risk of depression, suicidal ideation, poor sexual and reproductive health outcomes, and substance use compared with heterosexual cisgender youth.¹⁷

Providers first should routinely ask about an adolescent’s sexual orientation and gender identity. The American Academy of Pediatrics, the Society for Adolescent Health and Medicine, the Uniform Data System, and Meaningful Use Stage 3 have is- sued policy statements recommending routine collection of sexual orientation and gender identity as part of primary care for all patients, including adolescents.^18-20 In an AAP survey, only 18% of pediatricians reported routinely discussing SOGI with their patients.²¹ Routinely asking alerts adolescents that it is safe to disclose to their provider and that it is an opportunity for open dialogue. SMGD youth have described routinely wanting to disclose their SOGI to their providers.¹⁴

The preferred method of SOGI disclosure by age, sexual orientation, and gender identity is yet to be extensively researched, but routine and universal conversations about sexual orientation and gender identity create an environment of support and reassurance so that children feel safe raising questions and concerns. These routine, universal conversations also provide opportunities to teach and model to children and families the importance of inclusion, family support, and affirmation and that sexual and gender diversity is a normal, expected aspect of human development. The specific approach for SOGI assessment may vary depending on the age of the patient. For instance, to assess gender identity in school-age children, providers may ask parents about their child’s preferences for play, hair, and dress; about how their child reacts to gendered activities like having to “line up with all the girls” or use the “boys” bathroom at school; and whether they have concerns or questions about their child’s behavior with these activities. Providers can also ask children and younger adolescents how they like to play, dress, or wear their hair; or “When you think about who you are on the inside, do you feel more like a girl, a boy, neither, both, or something else?” In younger adolescents, sexual orientation may be assessed by asking about crushes or feelings toward other adolescent males or females. In older adolescents, the routine use of self-administered questionnaires is a suggested approach for asking about sexual orientation and gender identity that can enhance the accessibility of the information for further discussion during the visit. Providers can also ask patients to share about their gender journey, including what age they knew they were in the wrong body, feelings of discomfort with their body, or desire for secondary characteristics of the other gender.

Second, pediatricians can move beyond asking about sexual orientation and gender identity to affirming the patient’s identity. The first step is to provide developmentally appropriate care oriented toward understanding and appreciating the youth’s experience.²² This includes encouraging talk about identity and providing assurance that diverse sexual or gender identities are not a mental disorder, illness, or aberration but, rather, normal aspects of human diversity. Example affirmation statements include “Many of my patients begin to question their sexual identity as they grow older and that’s completely normal” and “You are not alone; it is very normal to have feelings and questions about your gender identity.” The purpose of this is to let the adolescent know that what they are experiencing is normal and that they are not alone. Providers can also create a setting that affirms adolescents’ sexual orientation and gender identity. These can be in the form of visual cues, such as posters featuring SMGD youth, badges with providers’ preferred pronouns, gender-neutral restrooms, and inclusive forms and patient materials that are gender neutral and nonheteronormative.

Pediatricians are uniquely situated to provide or refer SMGD youth to sources of needed health care. SMGD youth experience disproportionate rates of bullying and victimization, interpersonal and intimate partner violence, mental and behavioral health needs (eg, depression, anxiety, and suicidality), substance use disorder, and HIV and other sexually transmitted infections (STIs) compared with their heterosexual and cisgender peers.¹⁹ As with all youth, but particularly SMGD youth who are at greater risk, providers should be prepared to complete appropriate screening for these notable health and social disparities. They may be the first to identify a health or social need that requires treatment or referral. Bullying is a key area that may require identification and action. The GLSEN (formerly Gay, Lesbian & Straight Education Network) 2019 National School Climate Survey²³ and the Human Rights Comparison 2018 LGBTQ Youth Report¹³ both report high rates of bullying and victimization (including verbal, physical, electronic, and sexual harassment) among SMGD youth. Further, YRBS reports significantly higher rates of bullying and victimization among youth who identify as lesbian, gay, bisexual, or transgender compared with their heterosexual and cisgender peers.^2,24 Providers should ask about school, including safety inside and outside the building, and be prepared with guidance and resources if youth are feeling unsafe.

Finally, at all ages and at all stages of sexual and gender identity development, pediatric and adolescent medicine providers play a critical role in supporting, educating, and equipping parents with the tools needed to affirm their SMGD child and protect them against the negative effects of anti-LGBT stigma. Evidence is clear that family acceptance is associated with improved mental health, de- lay in engagement of substance use, and less engagement in sexual risk behavior. Studies have consistently shown that family acceptance during adolescence can be protective against depression, suicidality, substance use, HIV and STIs, and associated with higher reported social support, self-esteem, and general health.^25,26 The reverse is also unfortunately true. SMGD youth rejected by their families have higher rates of poor mental health outcomes, substance use, and sexual risk behaviors than SMGD who experience family acceptance and affirmation.^25,26 Parental and family affirmation and support are paramount to SMGD youth health and well-being. Pediatric and adolescent medicine providers should prioritize helping parents under- stand this. Similar to the approach we have recommended for SMGD youth, providers should also start by meeting parents where they are and inviting them to share their questions, feelings, beliefs, and concerns. However, providers’ advice and anticipatory guidance should be grounded in their evidence-based medical expertise about the importance of parent and family support. Providers should also remind parents of responsibilities that are important for all youth—parental monitoring, parent-child communication, and setting expectations and limit set- ting—and remain important as parents help their SMGD youth navigate the transition to adulthood.

By routinely creating a space of acceptance and support, pediatricians have an opportunity to improve the health outcomes of SMGD youth. They can create this space by asking consistent, routine questions about SOGI, linking youth to needed resources and referrals, and providing parents with the evidence, knowledge, and resources to help them support their children and adolescents. Using such an approach, pediatricians can help patients and families address the vulnerabilities that sexual minority and gender- diverse youth face, play a critical role in bolstering youth against these vulnerabilities, and help secure their health and well-being.

References

1. Kann L, Olsen EO, McManus T, et al. Sexual Identity, Sex of Sexual Contacts, and Health-Related Behaviors Among Students in Grades 9–12 — United States and Selected Sites, 2015. MMWR Surveill Summ 2016;65(No. SS-9):1-202. DOI: http://dx.doi.org/10.15585/mmwr.ss6509a12.Youth risk behavior surveillance system. Centers for Disease Control and Prevention. Updated October 27, 2020. Accessed May 4, 2021. https://www.cdc.gov/healthyyouth/data/yrbs/index.htm

2. Johns MM, Lowry R, Andrzejewski J, et al. Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students - 19 states and large urban school districts, 2017. MMWR Morb Mortal Wkly Rep. 2019;68(3):67-71. doi:10.15585/mmwr.mm6803a3

3. Herman JL, Flores AR, Brown TNT, Wilson BDM, Conron KJ. Age of individuals who identify as transgender in the United States. The Williams Institute, UCLA School of Law; 2017. Accessed April 25, 2021. https://williamsinstitute.law.ucla.edu/wp-content/uploads/Age-Trans-Individuals-Jan-2017.pdf .

4. Jones JM. LGBT identification rises to 5.6% in latest U.S. estimate. Gallup. February 24, 2021. Accessed April 25, 2021. https://news.gallup.com/poll/329708/lgbt-identification-rises-latest-estimate.aspx

5. Erikson EH. Growth and crises of the healthy personality. Psyche (Stuttg). 1953;7(1):1-31.

6. Sanders RA. Adolescent psychosocial, social, and cognitive development. Pediatr Rev. 2013;34(8):354-358. doi:10.1542/pir.34-8-354

7. Cass VC. Homosexuality identity formation: A theoretical model. J Homosex. 1979;4(3):219-235. doi:10.1300/J082v04n03_01

8. Mcneely C, Blanchard J. The teen years explained: A guide to healthy adolescent development; 2009. Accessed April 25, 2021. https://www.jhsph.edu/research/centers-and-institutes/center-for-adolescent-health/_docs/TTYE-Guide.pdf

9. Rosario M, Schrimshaw EW, Hunter J, Braun L. Sexual identity development among gay, lesbian, and bisexual youths: consistency and change over time. J Sex Res. 2006;43(1):46-58. doi:10.1080/00224490609552298

10. Fields E, Morgan A, Sanders RA. The intersection of sociocultural factors and health-related behavior in lesbian, gay, bisexual, and transgender youth: experiences among young black gay males as an example. Pediatr Clin North Am. 2016;63(6):1091-1106. doi:10.1016/j.pcl.2016.07.009

11 .Guss C, Shumer D, Katz-Wise SL. Transgender and gender nonconforming adolescent care: psychosocial and medical considerations. Curr Opin Pediatr. 2015;27(4):421-426. doi:10.1097/MOP.0000000000000240

12. White J, Sepúlveda MJ, Patterson CJ. Understanding the well-being of LGBTQI+ populations. National Academies Press; 2020. Accessed April 21, 2021. https://www.nap.edu/catalog/25877/understanding-the-well-being-of-lgbtqi-populations

13. Kahn E, Johnson A, Lee M, Miranda L. 2018 LGBTQ Youth Report. Accessed April 25, 2021. https://www.hrc.org/resources/2018-lgbtq-youth-report

14. Rossman K, Salamanca P, Macapagal K. A qualitative study examining young adults’ experiences of disclosure and nondisclosure of LGBTQ identity to health care providers. J Homosex. 2017;64(10):1390-1410. doi:10.1080/00918369.2017.1321379

15. When health care isn't caring: Lambda Legal’s survey of discrimination against LGBT people and people with HIV. Lambda Legal. Accessed April 21, 2021. https://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf

16. Smith DM, Mathews WC. Physicians’ attitudes toward homosexuality and HIV: survey of a California Medical Society- revisited (PATHH-II). J Homosex. 2007;52(3-4):1-9. doi:10.1300/J082v52n03_01

17. Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health care disparities among lesbian, gay, bisexual, and transgender youth: a literature review. Cureus. 2017;9(4):e1184. doi:10.7759/cureus.1184

18. Cahill S, Makadon HJ. Sexual orientation and gender identity data collection update: U.S. government takes steps to promote sexual orientation and gender identity data collection through meaningful use guidelines. LGBT Health. 2014;1(3):157-160. doi:10.1089/lgbt.2014.0033

19. Levine DA; Committee on Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics. 2013;132(1):e297-e313. doi:10.1542/peds.2013-1283

20. Reitman DS, Austin B, Belkind U, et al. Recommendations for promoting the health and well-being of lesbian, gay, bisexual, and transgender adolescents: a position paper of the Society for Adolescent Health and Medicine. J Adolesc Health. 2013;52(4):506-510. doi:10.1016/j.jadohealth.2013.01.015

21. Alexander SC, Fortenberry JD, Pollak KI, et al. Sexuality talk during adolescent health maintenance visits. JAMA Pediatr. 2014;168(2):163-169. doi:10.1001/jamapediatrics.2013.4338

22. Rafferty J, Committee on psychosocial aspects of child and family health; committee on adolescence; section on lesbian, gay, bisexual, and transgender health and wellness, Health F. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4):e20182162. doi:10.1542/peds.2018-2162

23 Kosciw JG, Clark CM, Truong NL, Zongrone AD. (2020). The 2019 national school climate survey: the experiences of lesbian, gay, bisexual, transgender, and queer youth in our nation’s schools. GLSEN. Accessed March 22, 2021. https://www.glsen.org/sites/default/files/2021-04/NSCS19-FullReport-032421-Web_0.pdf

24. Johns MM, Lowry R, Haderxhanaj LT, et al. Trends in violence victimization and suicide risk by sexual identity among high school students — Youth Risk Behavior Survey, United States, 2015-2019. August 21, 2020. Accessed March 22, 2021. https://www.cdc.gov/mmwr/volumes/69/su/su6901a3.htm

25. Russell ST, Fish JN. Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. Annu Rev Clin Psychol. 2016;12:465-487. doi:10.1146/annurev-clinpsy-021815-093153

26. Ryan C, Russell ST, Huebner D, Diaz R, Sanchez J. Family acceptance in adolescence and the health of LGBT young adults. J Child Adolesc Psychiatr Nurs. 2010;23(4):205-213. doi:10.1111/j.1744-6171.2010.00246.x