Gerald Montano, DO

The clinical management of transgender and gender nonconforming youth is a growing area in pediatric endocrinology and adolescent medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? Are children and adolescents capable of making life-changing decisions? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.

What are the risks of delaying transition until adulthood?

Available studies report the incidence of mental health problems among transgender and gender nonconforming youth are higher than the incidence in cisgender youth.¹ This is especially true if they are unable to live as the gender with which they identify. de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition.² This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes them to longer periods of gender dysphoria and to harassment and discrimination. There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery was done when the patient was younger with smaller breasts.³ Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age, which would prevent the development of the undesired secondary sex characteristics.

Can gender dysphoria be diagnosed at an early age?

Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty.^4,5 Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put them through unnecessary risks.

One potential treatment for some prepubertal children with gender dysphoria is social transition; for example, using the preferred name and pronouns, change of clothing and hairstyle, and so on. This is reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence. Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner Stage 2,^6,7 and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm their gender identity. Finally, children who have gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood.³

What are the medical risks with pubertal suppression and cross-sex hormones?

One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa) – such as leuprolide – is reduced bone mineral density (BMD).⁷ Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD,⁸ whereas other studies showed no difference in BMD between those treated with GnRHa versus those who were not,^9,10 especially after resumption of puberty.

What are the medical risks of using cross-sex hormones?

Likewise, use of cross-sex hormones – like estrogen and testosterone – is not risk free. The most likely risks with estrogen are venous thromboembolic events including pulmonary emboli, blood clots, gallstones, elevated liver enzymes, weight gain, and high cholesterol. Polycythemia, weight gain, acne, male pattern baldness, and sleep apnea are risks associated with testosterone use.⁷ Additionally, use of these hormones can induce infertility, and this is not always reversible.⁶ Furthermore, there are some studies in animal and human models that highlight the importance of sex hormones in organizing the brain during the critical period of adolescence.¹¹ There is some concern that pubertal suppression or the use of cross-sex hormones for transition during this time may disrupt this process. However, one prospective study showed that adolescents who received pubertal suppression and cross-sex hormones had no psychopathology as adults and even had improved mental health outcomes.¹² Nevertheless, this is only one study and further studies should confirm that pubertal suppression and sex reassignment are beneficial to the patient.

Can children and adolescents make complex, life-changing decisions?

The ethical issues of managing gender dysphoria in children and adolescents are the avoidance of harm – in both treatment and delaying treatment until the patient is older – and determining if children and adolescents are capable of making important decisions. Many would argue that children are not capable of making complex, life-changing decisions. For example, we wouldn’t expect an 8-year-old recently diagnosed with cancer to decide whether to proceed with treatment, knowing the potential side effects. Nevertheless, the recommended treatment for children is social transition. This process is reversible with little psychological and medical consequences.

However, adolescence can cloud the issue. Depending on the state, teenagers can obtain care for sexually transmitted infections (STIs) and contraception services without parental consent. Prevention of the spread of STIs and unwanted pregnancy are the primary rationales behind this, as adolescents are less likely to obtain these services if doing so required parental consent.¹³ However, underlying this rationale is the belief that adolescents are capable of making some complex decisions. Although the treatment of STIs or preventing unwanted pregnancy is not as complex as pubertal suppression or use of cross-sex hormones, the consequences of foregoing medical care of STIs (for example, the possibility of infertility due to pelvic inflammatory disease) or unexpected pregnancy are also life-changing.

One also must remember that not all adolescents reach their developmental milestones at the same age. A 14-year-old may have cognitive and executive functioning advanced for their age whereas an 18-year-old may lack these skills. Because of this variation, an interdisciplinary team including clinicians and behavioral/mental health experts should help individuals through the process of characterizing their self-identified gender identity and support their eventual transition using, as indicated for each individual, pubertal suppression, cross-sex hormones, and, ultimately, surgery.

The treatment of gender dysphoria in children and adolescents is characterized by ethical, medical, and psychosocial dilemmas. Long-term data are not available to determine the optimal age for transition for each individual. Despite the long-term risks, some children and adolescents are capable of making some important decisions. Furthermore, some treatment recommendations for children and adolescents who have gender dysphoria are reversible. At the end of the day, clinicians must combine the limited evidence with their experience to make the best judgment on how to proceed. Most important of all, they should allow the child to lead because he/she is the best judge of his/her gender identity.

References:

1. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011).

2. Psychiatry Res. 2011 Apr 30;186(2-3):414-8.

3. Nat Rev Endocrinol. 2011 May 17;7(8):466-72.

4. Dev Psychol. 2008 Jan;44(1):34-45.

5. J Adolesc Health. 2015 Oct;57(4):367-73.

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

7. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011; 7th ed.

8. J Clin Endocrinol Metab. 2008 Jan;93(1):190-5.

9. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17.

10. Clinics (Sao Paulo). 2012;67(6):591-6.

11. Front Neuroendocrinol. 2005 Oct-Dec;26(3-4):163-74.

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

13. Arch Pediatr Adolesc Med. 2000;154(9):885-92.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

The clinical management of transgender and gender nonconforming youth is a growing area in pediatric endocrinology and adolescent medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? Are children and adolescents capable of making life-changing decisions? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.

What are the risks of delaying transition until adulthood?

Available studies report the incidence of mental health problems among transgender and gender nonconforming youth are higher than the incidence in cisgender youth.¹ This is especially true if they are unable to live as the gender with which they identify. de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition.² This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes them to longer periods of gender dysphoria and to harassment and discrimination. There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery was done when the patient was younger with smaller breasts.³ Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age, which would prevent the development of the undesired secondary sex characteristics.

Can gender dysphoria be diagnosed at an early age?

Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty.^4,5 Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put them through unnecessary risks.

One potential treatment for some prepubertal children with gender dysphoria is social transition; for example, using the preferred name and pronouns, change of clothing and hairstyle, and so on. This is reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence. Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner Stage 2,^6,7 and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm their gender identity. Finally, children who have gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood.³

What are the medical risks with pubertal suppression and cross-sex hormones?

One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa) – such as leuprolide – is reduced bone mineral density (BMD).⁷ Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD,⁸ whereas other studies showed no difference in BMD between those treated with GnRHa versus those who were not,^9,10 especially after resumption of puberty.

What are the medical risks of using cross-sex hormones?

Likewise, use of cross-sex hormones – like estrogen and testosterone – is not risk free. The most likely risks with estrogen are venous thromboembolic events including pulmonary emboli, blood clots, gallstones, elevated liver enzymes, weight gain, and high cholesterol. Polycythemia, weight gain, acne, male pattern baldness, and sleep apnea are risks associated with testosterone use.⁷ Additionally, use of these hormones can induce infertility, and this is not always reversible.⁶ Furthermore, there are some studies in animal and human models that highlight the importance of sex hormones in organizing the brain during the critical period of adolescence.¹¹ There is some concern that pubertal suppression or the use of cross-sex hormones for transition during this time may disrupt this process. However, one prospective study showed that adolescents who received pubertal suppression and cross-sex hormones had no psychopathology as adults and even had improved mental health outcomes.¹² Nevertheless, this is only one study and further studies should confirm that pubertal suppression and sex reassignment are beneficial to the patient.

Can children and adolescents make complex, life-changing decisions?

The ethical issues of managing gender dysphoria in children and adolescents are the avoidance of harm – in both treatment and delaying treatment until the patient is older – and determining if children and adolescents are capable of making important decisions. Many would argue that children are not capable of making complex, life-changing decisions. For example, we wouldn’t expect an 8-year-old recently diagnosed with cancer to decide whether to proceed with treatment, knowing the potential side effects. Nevertheless, the recommended treatment for children is social transition. This process is reversible with little psychological and medical consequences.

However, adolescence can cloud the issue. Depending on the state, teenagers can obtain care for sexually transmitted infections (STIs) and contraception services without parental consent. Prevention of the spread of STIs and unwanted pregnancy are the primary rationales behind this, as adolescents are less likely to obtain these services if doing so required parental consent.¹³ However, underlying this rationale is the belief that adolescents are capable of making some complex decisions. Although the treatment of STIs or preventing unwanted pregnancy is not as complex as pubertal suppression or use of cross-sex hormones, the consequences of foregoing medical care of STIs (for example, the possibility of infertility due to pelvic inflammatory disease) or unexpected pregnancy are also life-changing.

One also must remember that not all adolescents reach their developmental milestones at the same age. A 14-year-old may have cognitive and executive functioning advanced for their age whereas an 18-year-old may lack these skills. Because of this variation, an interdisciplinary team including clinicians and behavioral/mental health experts should help individuals through the process of characterizing their self-identified gender identity and support their eventual transition using, as indicated for each individual, pubertal suppression, cross-sex hormones, and, ultimately, surgery.

The treatment of gender dysphoria in children and adolescents is characterized by ethical, medical, and psychosocial dilemmas. Long-term data are not available to determine the optimal age for transition for each individual. Despite the long-term risks, some children and adolescents are capable of making some important decisions. Furthermore, some treatment recommendations for children and adolescents who have gender dysphoria are reversible. At the end of the day, clinicians must combine the limited evidence with their experience to make the best judgment on how to proceed. Most important of all, they should allow the child to lead because he/she is the best judge of his/her gender identity.

References:

1. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011).

2. Psychiatry Res. 2011 Apr 30;186(2-3):414-8.

3. Nat Rev Endocrinol. 2011 May 17;7(8):466-72.

4. Dev Psychol. 2008 Jan;44(1):34-45.

5. J Adolesc Health. 2015 Oct;57(4):367-73.

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

7. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011; 7th ed.

8. J Clin Endocrinol Metab. 2008 Jan;93(1):190-5.

9. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17.

10. Clinics (Sao Paulo). 2012;67(6):591-6.

11. Front Neuroendocrinol. 2005 Oct-Dec;26(3-4):163-74.

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

13. Arch Pediatr Adolesc Med. 2000;154(9):885-92.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

The clinical management of transgender and gender nonconforming youth is a growing area in pediatric endocrinology and adolescent medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? Are children and adolescents capable of making life-changing decisions? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.

What are the risks of delaying transition until adulthood?

Available studies report the incidence of mental health problems among transgender and gender nonconforming youth are higher than the incidence in cisgender youth.¹ This is especially true if they are unable to live as the gender with which they identify. de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition.² This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes them to longer periods of gender dysphoria and to harassment and discrimination. There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery was done when the patient was younger with smaller breasts.³ Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age, which would prevent the development of the undesired secondary sex characteristics.

Can gender dysphoria be diagnosed at an early age?

Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty.^4,5 Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put them through unnecessary risks.

One potential treatment for some prepubertal children with gender dysphoria is social transition; for example, using the preferred name and pronouns, change of clothing and hairstyle, and so on. This is reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence. Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner Stage 2,^6,7 and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm their gender identity. Finally, children who have gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood.³

What are the medical risks with pubertal suppression and cross-sex hormones?

One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa) – such as leuprolide – is reduced bone mineral density (BMD).⁷ Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD,⁸ whereas other studies showed no difference in BMD between those treated with GnRHa versus those who were not,^9,10 especially after resumption of puberty.

What are the medical risks of using cross-sex hormones?

Likewise, use of cross-sex hormones – like estrogen and testosterone – is not risk free. The most likely risks with estrogen are venous thromboembolic events including pulmonary emboli, blood clots, gallstones, elevated liver enzymes, weight gain, and high cholesterol. Polycythemia, weight gain, acne, male pattern baldness, and sleep apnea are risks associated with testosterone use.⁷ Additionally, use of these hormones can induce infertility, and this is not always reversible.⁶ Furthermore, there are some studies in animal and human models that highlight the importance of sex hormones in organizing the brain during the critical period of adolescence.¹¹ There is some concern that pubertal suppression or the use of cross-sex hormones for transition during this time may disrupt this process. However, one prospective study showed that adolescents who received pubertal suppression and cross-sex hormones had no psychopathology as adults and even had improved mental health outcomes.¹² Nevertheless, this is only one study and further studies should confirm that pubertal suppression and sex reassignment are beneficial to the patient.

Can children and adolescents make complex, life-changing decisions?

The ethical issues of managing gender dysphoria in children and adolescents are the avoidance of harm – in both treatment and delaying treatment until the patient is older – and determining if children and adolescents are capable of making important decisions. Many would argue that children are not capable of making complex, life-changing decisions. For example, we wouldn’t expect an 8-year-old recently diagnosed with cancer to decide whether to proceed with treatment, knowing the potential side effects. Nevertheless, the recommended treatment for children is social transition. This process is reversible with little psychological and medical consequences.

However, adolescence can cloud the issue. Depending on the state, teenagers can obtain care for sexually transmitted infections (STIs) and contraception services without parental consent. Prevention of the spread of STIs and unwanted pregnancy are the primary rationales behind this, as adolescents are less likely to obtain these services if doing so required parental consent.¹³ However, underlying this rationale is the belief that adolescents are capable of making some complex decisions. Although the treatment of STIs or preventing unwanted pregnancy is not as complex as pubertal suppression or use of cross-sex hormones, the consequences of foregoing medical care of STIs (for example, the possibility of infertility due to pelvic inflammatory disease) or unexpected pregnancy are also life-changing.

One also must remember that not all adolescents reach their developmental milestones at the same age. A 14-year-old may have cognitive and executive functioning advanced for their age whereas an 18-year-old may lack these skills. Because of this variation, an interdisciplinary team including clinicians and behavioral/mental health experts should help individuals through the process of characterizing their self-identified gender identity and support their eventual transition using, as indicated for each individual, pubertal suppression, cross-sex hormones, and, ultimately, surgery.

The treatment of gender dysphoria in children and adolescents is characterized by ethical, medical, and psychosocial dilemmas. Long-term data are not available to determine the optimal age for transition for each individual. Despite the long-term risks, some children and adolescents are capable of making some important decisions. Furthermore, some treatment recommendations for children and adolescents who have gender dysphoria are reversible. At the end of the day, clinicians must combine the limited evidence with their experience to make the best judgment on how to proceed. Most important of all, they should allow the child to lead because he/she is the best judge of his/her gender identity.

References:

1. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011).

2. Psychiatry Res. 2011 Apr 30;186(2-3):414-8.

3. Nat Rev Endocrinol. 2011 May 17;7(8):466-72.

4. Dev Psychol. 2008 Jan;44(1):34-45.

5. J Adolesc Health. 2015 Oct;57(4):367-73.

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

7. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011; 7th ed.

8. J Clin Endocrinol Metab. 2008 Jan;93(1):190-5.

9. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17.

10. Clinics (Sao Paulo). 2012;67(6):591-6.

11. Front Neuroendocrinol. 2005 Oct-Dec;26(3-4):163-74.

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

13. Arch Pediatr Adolesc Med. 2000;154(9):885-92.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

A mentor told me during my pediatrics residency that going to school is “the main job of a teenager.” This is because at school, teenagers will be spending the majority of their time and energy learning and growing to become a thriving adult. However, the school environment matters. We are familiar with how excellent teachers, the availability of tutoring, and an administration dedicated to academic achievement play a big role. We also should be aware that if teenagers feel unsafe going to school – especially if they are victims of bullying – they are unable to take advantage of these resources.

Bullying is a repetitive, unwanted, and aggressive behavior among children and adolescents that involves a real or perceived power imbalance.¹ Despite the increasing visibility of lesbian, gay, bisexual, and transgender (LGBT) individuals, bullying remains a serious problem for this population. Although between one in four and one in three of all youth experience bullying,² according to the Youth Risk Behavior Survey, LGBT students are two to four times as likely to be threatened or injured with a weapon on school property, two to three times as likely not to go to school because they feel unsafe, and about two times as likely to be bullied at school, compared with their heterosexual peers.³ Alarmingly, more than half of transgender students experience bullying and harassment at school.⁴

A key component of bullying is the power imbalance. Bullying perpetrators feel that they have more power physically (e.g., in size) or socially (e.g., in social status).⁵ LGBT youth are often the victims of bullying because of the societal stigma against same-sex attraction or gender nonconformity. As a result, they tend to have a lower social status, putting them at risk for bullying. Remember, however, that this power imbalance is perceived. Even straight teenagers can be victims of antigay and antitrans bullying because they don’t conform to gender norms (e.g., a straight boy interested in theater instead of sports).⁶ Therefore, any teenager can be a victim of antigay and antitrans bullying.

Although many believe that experiencing bullying is a “rite of passage,” a look at the research on bullying contradicts this. Youth who experience bullying have higher rates of depression, loneliness, and, most worrisome of all, suicide.^7,8 One study showed that LGBT youth who experience bullying are almost six times as likely to consider suicide.⁹ Such sobering statistics prove that bullying is harmful. Furthermore, the effects of bullying can last into adulthood. One study showed that LGBT youth who experienced bullying during high school are more likely to have depressive symptoms and to be dissatisfied with life as a young adult.¹⁰ If rites of passage are designed to make a teenager into a well-adjusted young adult, then bullying does a poor job.

Although antigay bullying and harassment occur outside the clinic, providers can encounter both the perpetrator and the victim as patients and not realize it. Providers who have patients at risk for bullying – such as LGBT or gender-nonconforming youth – should routinely ask them about bullying through such questions as:

• “How many good friends do you have in school?”

• “Do you ever feel afraid to go to school? Why?”

• “Do other kids ever bully you at school, in your neighborhood, or online? Who bullies you?

• When and where does it happen? What do they say or do?”¹¹

Asking these questions is especially important if you or your patient’s caregivers notice school phobia, attention problems, or psychosomatic complaints.11 Once you identify a victim, refer the patient to a mental health provider to develop skills to cope with the stress of bullying. Such skills include how to make friends. Emphasize that it is not the victim’s fault that they are experiencing bullying. Avoid telling victims to fight back or “suck it up.” In addition, work with parents and school authorities to intervene on behalf of the child to stop the bullying behavior.

Lisa Quarfoth/Thinkstock

At the same time, it is especially important to identify perpetrators. Perpetrators tend to have conduct problems, increased depressive symptoms, and poor school adjustment.¹² They may have been bullied themselves. Also refer perpetrators to a mental health provider and other resources to address these problems.

However, with your limited time to screen for bullying or to create an individualized plan to protect bullying victims, approaches to reducing bullying and their adverse effects require a community effort. Use your expertise and access to the latest scientific research to advocate and help create policies schools can use to address antigay bullying. Clark and Tilly recommend a three-tier approach in addressing antigay bullying. In the first tier, schools should create a safe and affirmative environment for all students. An example of such an approach is to have a speaker – such as a physician from the community – talking to students about bullying and encouraging bystanders to speak up (i.e., be an ally) for bullying victims. Although some schools may be hesitant to implement a schoolwide intervention, they may implement a second-tier approach, such as classroom curricula on how to be an ally or incentive programs for helping vulnerable students (e.g., tutoring). Finally, the third tier requires intensive individualized interventions for bullying victims. Schools should have a step-by-step plan involving school authorities that students and their parents can use if students are experiencing bullying.¹³ Implementation of this plan requires timely follow-up from school officials to ensure cessation of the bullying behavior.10

Another way you can advocate for your LGBT patients is to be knowledgeable about the laws surrounding bullying. Bullying laws vary according to state. This is especially true if such laws specifically prohibit bullying based on sexual orientation or gender identity. This is known as “enumeration.” Enumerated laws grant school authorities the power to prevent and to correct any bullying based on sexual orientation and gender identity. Currently, 18 states and the District of Columbia have enumerated antibullying laws.¹⁴ If you live in a state that does not have an enumerated antibullying law, you can contact your state government officials to urge them to pass such a law.

Bullying has a powerful impact on the health and well-being of LGBT youth. Screen for bullying in your LGBT patients and work with schools and parents to protect them from such behaviors. Most importantly, advocate for creating a safe school environment for LGBT youth so that they can focus on their main job of learning and becoming a thriving adult.

Resources

• The website www.stopbullying.gov is a comprehensive resource for bullying and how to address it.

• Society of Adolescent Health & Medicine (SAHM) position statement on bullying (J Adolesc Health. 2005 Jan;36[1]:88-91).

• American Academy of Pediatrics (AAP) position statement on bullying (Pediatrics. 2009 July. doi: 10.1542/peds.2009-0943).

• Gay, Lesbian & Straight Education Network (GLSEN) information on enumerated antibullying laws by state (www.glsen.org/article/state-maps).

References

1. Bullying definition at www.stopbullying.gov.

2. Student Reports of Bullying and Cyber-Bullying: Results From the 2011 School Crime Supplement to the National Crime Victimization Survey.

3. J Adolesc Health. 2014 Sep;55(3):432-8.

4. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.

5. Can Fam Physician. 2009 Apr;55(4):356-60.

6. J Adolesc Health. 2016 Feb;58(2):S1-S2.

7. Pediatrics. 2003;111(6 Pt 1):1312-7.

8. Journal of Educational Psychology. 2000 Jun;92(2):349-59.

9. Prev Sci. 2015 Apr;16(3):451-62.

10. Dev Psychol. 2010 Nov;46(6):1580-9.

11. Roles for pediatricians in bullying prevention and intervention (www.stopbullying.gov/resources-files/roles-for-pediatricians-tipsheet.pdf).

12. J Adolesc Health. 2005 Jan;36(1):88-91.

13. Clark JP, Tilly, WD. The evolution of response to intervention. In: Clark JP, Alvarez, Michelle, ed. Response to intervention: A guide for school social worker. (New York: Oxford University Press; 2010:3-18).

14. Enumerated antibullying laws by state(www.glsen.org/article/state-maps).

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh.

A mentor told me during my pediatrics residency that going to school is “the main job of a teenager.” This is because at school, teenagers will be spending the majority of their time and energy learning and growing to become a thriving adult. However, the school environment matters. We are familiar with how excellent teachers, the availability of tutoring, and an administration dedicated to academic achievement play a big role. We also should be aware that if teenagers feel unsafe going to school – especially if they are victims of bullying – they are unable to take advantage of these resources.

Bullying is a repetitive, unwanted, and aggressive behavior among children and adolescents that involves a real or perceived power imbalance.¹ Despite the increasing visibility of lesbian, gay, bisexual, and transgender (LGBT) individuals, bullying remains a serious problem for this population. Although between one in four and one in three of all youth experience bullying,² according to the Youth Risk Behavior Survey, LGBT students are two to four times as likely to be threatened or injured with a weapon on school property, two to three times as likely not to go to school because they feel unsafe, and about two times as likely to be bullied at school, compared with their heterosexual peers.³ Alarmingly, more than half of transgender students experience bullying and harassment at school.⁴

A key component of bullying is the power imbalance. Bullying perpetrators feel that they have more power physically (e.g., in size) or socially (e.g., in social status).⁵ LGBT youth are often the victims of bullying because of the societal stigma against same-sex attraction or gender nonconformity. As a result, they tend to have a lower social status, putting them at risk for bullying. Remember, however, that this power imbalance is perceived. Even straight teenagers can be victims of antigay and antitrans bullying because they don’t conform to gender norms (e.g., a straight boy interested in theater instead of sports).⁶ Therefore, any teenager can be a victim of antigay and antitrans bullying.

Although many believe that experiencing bullying is a “rite of passage,” a look at the research on bullying contradicts this. Youth who experience bullying have higher rates of depression, loneliness, and, most worrisome of all, suicide.^7,8 One study showed that LGBT youth who experience bullying are almost six times as likely to consider suicide.⁹ Such sobering statistics prove that bullying is harmful. Furthermore, the effects of bullying can last into adulthood. One study showed that LGBT youth who experienced bullying during high school are more likely to have depressive symptoms and to be dissatisfied with life as a young adult.¹⁰ If rites of passage are designed to make a teenager into a well-adjusted young adult, then bullying does a poor job.

Although antigay bullying and harassment occur outside the clinic, providers can encounter both the perpetrator and the victim as patients and not realize it. Providers who have patients at risk for bullying – such as LGBT or gender-nonconforming youth – should routinely ask them about bullying through such questions as:

• “How many good friends do you have in school?”

• “Do you ever feel afraid to go to school? Why?”

• “Do other kids ever bully you at school, in your neighborhood, or online? Who bullies you?

• When and where does it happen? What do they say or do?”¹¹

Asking these questions is especially important if you or your patient’s caregivers notice school phobia, attention problems, or psychosomatic complaints.11 Once you identify a victim, refer the patient to a mental health provider to develop skills to cope with the stress of bullying. Such skills include how to make friends. Emphasize that it is not the victim’s fault that they are experiencing bullying. Avoid telling victims to fight back or “suck it up.” In addition, work with parents and school authorities to intervene on behalf of the child to stop the bullying behavior.

Lisa Quarfoth/Thinkstock

At the same time, it is especially important to identify perpetrators. Perpetrators tend to have conduct problems, increased depressive symptoms, and poor school adjustment.¹² They may have been bullied themselves. Also refer perpetrators to a mental health provider and other resources to address these problems.

However, with your limited time to screen for bullying or to create an individualized plan to protect bullying victims, approaches to reducing bullying and their adverse effects require a community effort. Use your expertise and access to the latest scientific research to advocate and help create policies schools can use to address antigay bullying. Clark and Tilly recommend a three-tier approach in addressing antigay bullying. In the first tier, schools should create a safe and affirmative environment for all students. An example of such an approach is to have a speaker – such as a physician from the community – talking to students about bullying and encouraging bystanders to speak up (i.e., be an ally) for bullying victims. Although some schools may be hesitant to implement a schoolwide intervention, they may implement a second-tier approach, such as classroom curricula on how to be an ally or incentive programs for helping vulnerable students (e.g., tutoring). Finally, the third tier requires intensive individualized interventions for bullying victims. Schools should have a step-by-step plan involving school authorities that students and their parents can use if students are experiencing bullying.¹³ Implementation of this plan requires timely follow-up from school officials to ensure cessation of the bullying behavior.10

Another way you can advocate for your LGBT patients is to be knowledgeable about the laws surrounding bullying. Bullying laws vary according to state. This is especially true if such laws specifically prohibit bullying based on sexual orientation or gender identity. This is known as “enumeration.” Enumerated laws grant school authorities the power to prevent and to correct any bullying based on sexual orientation and gender identity. Currently, 18 states and the District of Columbia have enumerated antibullying laws.¹⁴ If you live in a state that does not have an enumerated antibullying law, you can contact your state government officials to urge them to pass such a law.

Bullying has a powerful impact on the health and well-being of LGBT youth. Screen for bullying in your LGBT patients and work with schools and parents to protect them from such behaviors. Most importantly, advocate for creating a safe school environment for LGBT youth so that they can focus on their main job of learning and becoming a thriving adult.

Resources

• The website www.stopbullying.gov is a comprehensive resource for bullying and how to address it.

• Society of Adolescent Health & Medicine (SAHM) position statement on bullying (J Adolesc Health. 2005 Jan;36[1]:88-91).

• American Academy of Pediatrics (AAP) position statement on bullying (Pediatrics. 2009 July. doi: 10.1542/peds.2009-0943).

• Gay, Lesbian & Straight Education Network (GLSEN) information on enumerated antibullying laws by state (www.glsen.org/article/state-maps).

References

1. Bullying definition at www.stopbullying.gov.

2. Student Reports of Bullying and Cyber-Bullying: Results From the 2011 School Crime Supplement to the National Crime Victimization Survey.

3. J Adolesc Health. 2014 Sep;55(3):432-8.

4. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.

5. Can Fam Physician. 2009 Apr;55(4):356-60.

6. J Adolesc Health. 2016 Feb;58(2):S1-S2.

7. Pediatrics. 2003;111(6 Pt 1):1312-7.

8. Journal of Educational Psychology. 2000 Jun;92(2):349-59.

9. Prev Sci. 2015 Apr;16(3):451-62.

10. Dev Psychol. 2010 Nov;46(6):1580-9.

11. Roles for pediatricians in bullying prevention and intervention (www.stopbullying.gov/resources-files/roles-for-pediatricians-tipsheet.pdf).

12. J Adolesc Health. 2005 Jan;36(1):88-91.

13. Clark JP, Tilly, WD. The evolution of response to intervention. In: Clark JP, Alvarez, Michelle, ed. Response to intervention: A guide for school social worker. (New York: Oxford University Press; 2010:3-18).

14. Enumerated antibullying laws by state(www.glsen.org/article/state-maps).

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh.

A mentor told me during my pediatrics residency that going to school is “the main job of a teenager.” This is because at school, teenagers will be spending the majority of their time and energy learning and growing to become a thriving adult. However, the school environment matters. We are familiar with how excellent teachers, the availability of tutoring, and an administration dedicated to academic achievement play a big role. We also should be aware that if teenagers feel unsafe going to school – especially if they are victims of bullying – they are unable to take advantage of these resources.

Bullying is a repetitive, unwanted, and aggressive behavior among children and adolescents that involves a real or perceived power imbalance.¹ Despite the increasing visibility of lesbian, gay, bisexual, and transgender (LGBT) individuals, bullying remains a serious problem for this population. Although between one in four and one in three of all youth experience bullying,² according to the Youth Risk Behavior Survey, LGBT students are two to four times as likely to be threatened or injured with a weapon on school property, two to three times as likely not to go to school because they feel unsafe, and about two times as likely to be bullied at school, compared with their heterosexual peers.³ Alarmingly, more than half of transgender students experience bullying and harassment at school.⁴

A key component of bullying is the power imbalance. Bullying perpetrators feel that they have more power physically (e.g., in size) or socially (e.g., in social status).⁵ LGBT youth are often the victims of bullying because of the societal stigma against same-sex attraction or gender nonconformity. As a result, they tend to have a lower social status, putting them at risk for bullying. Remember, however, that this power imbalance is perceived. Even straight teenagers can be victims of antigay and antitrans bullying because they don’t conform to gender norms (e.g., a straight boy interested in theater instead of sports).⁶ Therefore, any teenager can be a victim of antigay and antitrans bullying.

Although many believe that experiencing bullying is a “rite of passage,” a look at the research on bullying contradicts this. Youth who experience bullying have higher rates of depression, loneliness, and, most worrisome of all, suicide.^7,8 One study showed that LGBT youth who experience bullying are almost six times as likely to consider suicide.⁹ Such sobering statistics prove that bullying is harmful. Furthermore, the effects of bullying can last into adulthood. One study showed that LGBT youth who experienced bullying during high school are more likely to have depressive symptoms and to be dissatisfied with life as a young adult.¹⁰ If rites of passage are designed to make a teenager into a well-adjusted young adult, then bullying does a poor job.

Although antigay bullying and harassment occur outside the clinic, providers can encounter both the perpetrator and the victim as patients and not realize it. Providers who have patients at risk for bullying – such as LGBT or gender-nonconforming youth – should routinely ask them about bullying through such questions as:

• “How many good friends do you have in school?”

• “Do you ever feel afraid to go to school? Why?”

• “Do other kids ever bully you at school, in your neighborhood, or online? Who bullies you?

• When and where does it happen? What do they say or do?”¹¹

Asking these questions is especially important if you or your patient’s caregivers notice school phobia, attention problems, or psychosomatic complaints.11 Once you identify a victim, refer the patient to a mental health provider to develop skills to cope with the stress of bullying. Such skills include how to make friends. Emphasize that it is not the victim’s fault that they are experiencing bullying. Avoid telling victims to fight back or “suck it up.” In addition, work with parents and school authorities to intervene on behalf of the child to stop the bullying behavior.

Lisa Quarfoth/Thinkstock

At the same time, it is especially important to identify perpetrators. Perpetrators tend to have conduct problems, increased depressive symptoms, and poor school adjustment.¹² They may have been bullied themselves. Also refer perpetrators to a mental health provider and other resources to address these problems.

However, with your limited time to screen for bullying or to create an individualized plan to protect bullying victims, approaches to reducing bullying and their adverse effects require a community effort. Use your expertise and access to the latest scientific research to advocate and help create policies schools can use to address antigay bullying. Clark and Tilly recommend a three-tier approach in addressing antigay bullying. In the first tier, schools should create a safe and affirmative environment for all students. An example of such an approach is to have a speaker – such as a physician from the community – talking to students about bullying and encouraging bystanders to speak up (i.e., be an ally) for bullying victims. Although some schools may be hesitant to implement a schoolwide intervention, they may implement a second-tier approach, such as classroom curricula on how to be an ally or incentive programs for helping vulnerable students (e.g., tutoring). Finally, the third tier requires intensive individualized interventions for bullying victims. Schools should have a step-by-step plan involving school authorities that students and their parents can use if students are experiencing bullying.¹³ Implementation of this plan requires timely follow-up from school officials to ensure cessation of the bullying behavior.10

Another way you can advocate for your LGBT patients is to be knowledgeable about the laws surrounding bullying. Bullying laws vary according to state. This is especially true if such laws specifically prohibit bullying based on sexual orientation or gender identity. This is known as “enumeration.” Enumerated laws grant school authorities the power to prevent and to correct any bullying based on sexual orientation and gender identity. Currently, 18 states and the District of Columbia have enumerated antibullying laws.¹⁴ If you live in a state that does not have an enumerated antibullying law, you can contact your state government officials to urge them to pass such a law.

Bullying has a powerful impact on the health and well-being of LGBT youth. Screen for bullying in your LGBT patients and work with schools and parents to protect them from such behaviors. Most importantly, advocate for creating a safe school environment for LGBT youth so that they can focus on their main job of learning and becoming a thriving adult.

Resources

• The website www.stopbullying.gov is a comprehensive resource for bullying and how to address it.

• Society of Adolescent Health & Medicine (SAHM) position statement on bullying (J Adolesc Health. 2005 Jan;36[1]:88-91).

• American Academy of Pediatrics (AAP) position statement on bullying (Pediatrics. 2009 July. doi: 10.1542/peds.2009-0943).

• Gay, Lesbian & Straight Education Network (GLSEN) information on enumerated antibullying laws by state (www.glsen.org/article/state-maps).

References

1. Bullying definition at www.stopbullying.gov.

2. Student Reports of Bullying and Cyber-Bullying: Results From the 2011 School Crime Supplement to the National Crime Victimization Survey.

3. J Adolesc Health. 2014 Sep;55(3):432-8.

4. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.

5. Can Fam Physician. 2009 Apr;55(4):356-60.

6. J Adolesc Health. 2016 Feb;58(2):S1-S2.

7. Pediatrics. 2003;111(6 Pt 1):1312-7.

8. Journal of Educational Psychology. 2000 Jun;92(2):349-59.

9. Prev Sci. 2015 Apr;16(3):451-62.

10. Dev Psychol. 2010 Nov;46(6):1580-9.

11. Roles for pediatricians in bullying prevention and intervention (www.stopbullying.gov/resources-files/roles-for-pediatricians-tipsheet.pdf).

12. J Adolesc Health. 2005 Jan;36(1):88-91.

13. Clark JP, Tilly, WD. The evolution of response to intervention. In: Clark JP, Alvarez, Michelle, ed. Response to intervention: A guide for school social worker. (New York: Oxford University Press; 2010:3-18).

14. Enumerated antibullying laws by state(www.glsen.org/article/state-maps).

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh.

Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.

Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:

Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.¹

Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.²

Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.³ This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.

Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.

Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.⁴ However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.

Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,⁵ but don’t forget that young lesbian women may have had sex with men.

Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.⁶ Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.

Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.

Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.

Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.⁷

Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,⁸ because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.⁹

So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.

The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:

• Ask, “Are your sexual partner’s male, female, or both?”

• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”

• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”

• Ask, “Have you ever had an STI, and if so, how was it treated?”

• Ask, “What do you use for birth control?” either hormonal or barrier methods.

In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.

Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”

By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.

Here are some resources on sex and relationships in LGBT youth:

• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.

• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.

• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.

References

1. J Bisex. 2000;1(1):31-68.

2. National Transgender Discrimination Survey: Full Report. 2012.

3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.

4. J Youth Adolesc. 2015 Jan;44(1):211-24.

5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7.

6. Sex Transm Dis. 2010 May;37(5):335-9.

7. Sexpress: The Toronto teen survey report. 2009.

8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.

9. Can J Hum Sex. 2008;17(3):123-139.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.

Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.

Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:

Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.¹

Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.²

Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.³ This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.

Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.

Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.⁴ However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.

Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,⁵ but don’t forget that young lesbian women may have had sex with men.

Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.⁶ Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.

Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.

Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.

Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.⁷

Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,⁸ because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.⁹

So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.

The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:

• Ask, “Are your sexual partner’s male, female, or both?”

• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”

• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”

• Ask, “Have you ever had an STI, and if so, how was it treated?”

• Ask, “What do you use for birth control?” either hormonal or barrier methods.

In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.

Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”

By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.

Here are some resources on sex and relationships in LGBT youth:

• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.

• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.

• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.

References

1. J Bisex. 2000;1(1):31-68.

2. National Transgender Discrimination Survey: Full Report. 2012.

3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.

4. J Youth Adolesc. 2015 Jan;44(1):211-24.

5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7.

6. Sex Transm Dis. 2010 May;37(5):335-9.

7. Sexpress: The Toronto teen survey report. 2009.

8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.

9. Can J Hum Sex. 2008;17(3):123-139.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.

Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.

Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:

Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.¹

Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.²

Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.³ This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.

Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.

Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.⁴ However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.

Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,⁵ but don’t forget that young lesbian women may have had sex with men.

Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.⁶ Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.

Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.

Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.

Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.⁷

Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,⁸ because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.⁹

So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.

The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:

• Ask, “Are your sexual partner’s male, female, or both?”

• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”

• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”

• Ask, “Have you ever had an STI, and if so, how was it treated?”

• Ask, “What do you use for birth control?” either hormonal or barrier methods.

In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.

Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”

By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.

Here are some resources on sex and relationships in LGBT youth:

• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.

• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.

• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.

References

1. J Bisex. 2000;1(1):31-68.

2. National Transgender Discrimination Survey: Full Report. 2012.

3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.

4. J Youth Adolesc. 2015 Jan;44(1):211-24.

5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7.

6. Sex Transm Dis. 2010 May;37(5):335-9.

7. Sexpress: The Toronto teen survey report. 2009.

8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.

9. Can J Hum Sex. 2008;17(3):123-139.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.

Two years ago, a mother of one of my patients asked me for advice. She knew that her daughter identified as lesbian, and she was fully supportive. One day, her daughter wanted to go to a sleepover at a female friend’s house. Her first reaction was to say yes, but then she had second thoughts: If her daughter were straight, and this friend were male, she would not allow her to go because of the potential for sexual activity. When she told her daughter she could not attend the sleepover, her daughter accused her of not letting her go because of her sexual orientation. And now, the dilemma: In her effort to be fair and consistent with her values, the mother is being accused of discrimination. What should she do?

Parents play an irreplaceable role in the life of any teen, especially in the lives of teens that identify as lesbian, gay, bisexual, or transgender (LGBT). But many LGBT youth face serious challenges with their parents. They face the potential of parental rejection of their sexual or gender identity. At the very worst, teens may face homelessness if they come out to homophobic parents.¹ Youth whose parents are accepting, nevertheless, are less likely to have mental health problems or engage in substance use.²

As a clinical provider for children and adolescents, caregivers will ask you for advice on how to address parenting challenges. Because LGBT youth are at risk for many adverse health outcomes, and parental support is paramount in preventing them, this is an opportunity for you to help this vulnerable population.

If parents ask you how to be supportive of their LGBT children, here are some recommendations, which are based on an intervention by colleagues at the University of Utah:³

1. Let their affection show. Receiving news that a child is LGBT can be emotionally intense for parents.⁴ Because of this emotional intensity, parents may react negatively and neglect to show their love for their child, which is what the child is seeking. Parents showing affection is the first step in supporting their LGBT child. Remind parents to tell their child that they love them no matter what.

2. Avoid rejecting behaviors. This is sometimes hard, because some forms of rejection can be quite subtle. Avoid saying anything that may indicate a negative view of LGBT people, even if it is not intended. For example, saying that something is “gay” may seem innocent enough, but it sends the message that being gay is something to be ashamed of.

3. Express their pain away from their child. Evidence shows that minimizing a child’s exposure to parental conflict and stress is associated with better coping with these devastating events.⁵ Parents should avoid telling their children that news of their sexual orientation or gender identity upsets them, as this is another form of rejecting behavior.

4. Do good before they feel good. Previous studies suggest that changes in behavior can occur even though a person may feel otherwise.⁶ Negative feelings about a child’s sexual orientation or gender identity can last months or years.⁷ It’s okay to have these feelings, but showing support such as telling their child how they still love them can ultimately lead to acceptance.

Although it is important for parents to accept their child, it is only half the battle. If you remember Baumrind’s theory on parenting, there are two sides of parenting. The first side involves parents showing their affection, love, and support for their children, which I described earlier. The other side involves managing a child’s behaviors, whether parents create an environment that makes it difficult to engage in behaviors they disapprove of or teach their children how to make the right decision.⁸ Many LGBT youth engage in risky behaviors because it’s a way of coping in a homophobic environment. The parents’ job is to teach their children healthier coping strategies.

Research on this aspect of parenting in LGBT youth is still at its infancy, and some of it is not reassuring. One important behavior, parental monitoring, which is “a set of correlated parenting behaviors involving attention to and tracking of the child’s whereabouts, activities, and adaptations,”⁹ can prevent conduct disorders, substance use, and mental health problems in the typical teenager.¹⁰ Unfortunately, we don’t find the same results for sexual minorities. One study suggests that parental monitoring may not prevent high-risk sexual behavior for young gay males, even if the parent is aware of the young man’s sexual orientation.¹¹

This doesn’t mean that parental monitoring isn’t helpful. This just means that parenting LGBT youth is different than parenting heterosexual youth. It’s not enough for parents to just accept their child’s sexual orientation. They also must help them make the right decisions taking into consideration the effect of stigma and discrimination on sexual minorities. There are a couple of things you can suggest to your parents to help them raise their LGBT children:

1. Be proactive. Join organizations that support parents of LGBT youth such as Parents, Families, and Friends of Lesbians and Gays (PFLAG). Also, parents must be aware of their children’s behavior. If they are acting depressed, seek help. Having depression or anxiety increases the chances of engaging in risky behaviors, so the earlier parents address this, the better.

2. Make their child know what their views are on high risk-behaviors, such as substance use or having unprotected sex. They need to communicate their expectations clearly. If parents believe that drinking alcohol before the legal age is wrong, they should clearly let their children know that.

3. Make it easier for their child to tell parents what’s going on in their lives. Parents have to gain their children’s trust, be accessible (don’t answer texts while talking to them!), and be an active listener. LGBT youth may not ask parents for advice because they feel that because their parents are straight or cisgender, their life experiences do not apply. Being a member of an organization like PLFAG can be helpful, because parents can ask other parents who have experience raising LGBT youth for advice that works.

4. If parents’ children do something wrong, they should talk to them about how their actions were risky. Children will listen to parents if they view their parenting as legitimate and fair, which can only happen if there is a strong parent-child relationship. Being supportive of a child’s sexual orientation or gender identity is key here. And for the next time, it’s always good to role-play a scenario (for example, what to do if someone tries to make them drink at a party).

Parents of LGBT youth face many challenges. You can help these parents by encouraging them to accept and support their child’s sexual orientation or gender identity and provide parenting strategies relevant for LGBT youth. Most important of all, encourage them to seek support through organizations like PFLAG. With this support, parents can encourage healthy development in LGBT youth.

Resources for parents of LGBT youth

• The Centers for Disease Control and Prevention (CDC) has information on the health of LGBT Youth and advice on parental monitoring in general.

• The Family Acceptance Project is a project researching ways to improve parent-child relationships in LGBT Youth.

• PFLAG is an organization that provides support for families of LGBT youth.

• Lead with Love is a film about how various types of families react to their children coming out to them.

References

1. J Sex Res. 2004 Nov;41(4):329-42.

2. Aust N Z J Psychiatry. 2010 Sep;44(9):774-83.

3. Huebner D. “Leading with Love: Interventions to Support Families of Lesbian, Gay, and Bisexual Adolescents,” The Register Report, Vol. 39. National Register of Health Service Psychologists, Spring 2013.

4. J GLBT Fam Stud. 2014 Jan;10(1-2):36-57.

5. Prof Psychol Res Pr. 2008 Apr;39(2):113-21.

6. “Behaviorism: Classic Studies” (Casper, Wyo: Endeavor Books/Mountain States Litho, 2009).

7. Journal of LGBT Issues in Counseling. 2008;2(2):126-58.

8. Genet Psychol Monogr. 1967;75(1):43-88.

9. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.

10. “Parental Monitoring of Adolescents: Current Perspectives for Researchers and Practitioners” (New York: Columbia University Press, 2010).

11. AIDS Behav. 2014 Aug;18(8):1604-14.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

Two years ago, a mother of one of my patients asked me for advice. She knew that her daughter identified as lesbian, and she was fully supportive. One day, her daughter wanted to go to a sleepover at a female friend’s house. Her first reaction was to say yes, but then she had second thoughts: If her daughter were straight, and this friend were male, she would not allow her to go because of the potential for sexual activity. When she told her daughter she could not attend the sleepover, her daughter accused her of not letting her go because of her sexual orientation. And now, the dilemma: In her effort to be fair and consistent with her values, the mother is being accused of discrimination. What should she do?

Parents play an irreplaceable role in the life of any teen, especially in the lives of teens that identify as lesbian, gay, bisexual, or transgender (LGBT). But many LGBT youth face serious challenges with their parents. They face the potential of parental rejection of their sexual or gender identity. At the very worst, teens may face homelessness if they come out to homophobic parents.¹ Youth whose parents are accepting, nevertheless, are less likely to have mental health problems or engage in substance use.²

As a clinical provider for children and adolescents, caregivers will ask you for advice on how to address parenting challenges. Because LGBT youth are at risk for many adverse health outcomes, and parental support is paramount in preventing them, this is an opportunity for you to help this vulnerable population.

If parents ask you how to be supportive of their LGBT children, here are some recommendations, which are based on an intervention by colleagues at the University of Utah:³

1. Let their affection show. Receiving news that a child is LGBT can be emotionally intense for parents.⁴ Because of this emotional intensity, parents may react negatively and neglect to show their love for their child, which is what the child is seeking. Parents showing affection is the first step in supporting their LGBT child. Remind parents to tell their child that they love them no matter what.

2. Avoid rejecting behaviors. This is sometimes hard, because some forms of rejection can be quite subtle. Avoid saying anything that may indicate a negative view of LGBT people, even if it is not intended. For example, saying that something is “gay” may seem innocent enough, but it sends the message that being gay is something to be ashamed of.

3. Express their pain away from their child. Evidence shows that minimizing a child’s exposure to parental conflict and stress is associated with better coping with these devastating events.⁵ Parents should avoid telling their children that news of their sexual orientation or gender identity upsets them, as this is another form of rejecting behavior.

4. Do good before they feel good. Previous studies suggest that changes in behavior can occur even though a person may feel otherwise.⁶ Negative feelings about a child’s sexual orientation or gender identity can last months or years.⁷ It’s okay to have these feelings, but showing support such as telling their child how they still love them can ultimately lead to acceptance.

Although it is important for parents to accept their child, it is only half the battle. If you remember Baumrind’s theory on parenting, there are two sides of parenting. The first side involves parents showing their affection, love, and support for their children, which I described earlier. The other side involves managing a child’s behaviors, whether parents create an environment that makes it difficult to engage in behaviors they disapprove of or teach their children how to make the right decision.⁸ Many LGBT youth engage in risky behaviors because it’s a way of coping in a homophobic environment. The parents’ job is to teach their children healthier coping strategies.

Research on this aspect of parenting in LGBT youth is still at its infancy, and some of it is not reassuring. One important behavior, parental monitoring, which is “a set of correlated parenting behaviors involving attention to and tracking of the child’s whereabouts, activities, and adaptations,”⁹ can prevent conduct disorders, substance use, and mental health problems in the typical teenager.¹⁰ Unfortunately, we don’t find the same results for sexual minorities. One study suggests that parental monitoring may not prevent high-risk sexual behavior for young gay males, even if the parent is aware of the young man’s sexual orientation.¹¹

This doesn’t mean that parental monitoring isn’t helpful. This just means that parenting LGBT youth is different than parenting heterosexual youth. It’s not enough for parents to just accept their child’s sexual orientation. They also must help them make the right decisions taking into consideration the effect of stigma and discrimination on sexual minorities. There are a couple of things you can suggest to your parents to help them raise their LGBT children:

1. Be proactive. Join organizations that support parents of LGBT youth such as Parents, Families, and Friends of Lesbians and Gays (PFLAG). Also, parents must be aware of their children’s behavior. If they are acting depressed, seek help. Having depression or anxiety increases the chances of engaging in risky behaviors, so the earlier parents address this, the better.

2. Make their child know what their views are on high risk-behaviors, such as substance use or having unprotected sex. They need to communicate their expectations clearly. If parents believe that drinking alcohol before the legal age is wrong, they should clearly let their children know that.

3. Make it easier for their child to tell parents what’s going on in their lives. Parents have to gain their children’s trust, be accessible (don’t answer texts while talking to them!), and be an active listener. LGBT youth may not ask parents for advice because they feel that because their parents are straight or cisgender, their life experiences do not apply. Being a member of an organization like PLFAG can be helpful, because parents can ask other parents who have experience raising LGBT youth for advice that works.

4. If parents’ children do something wrong, they should talk to them about how their actions were risky. Children will listen to parents if they view their parenting as legitimate and fair, which can only happen if there is a strong parent-child relationship. Being supportive of a child’s sexual orientation or gender identity is key here. And for the next time, it’s always good to role-play a scenario (for example, what to do if someone tries to make them drink at a party).

Parents of LGBT youth face many challenges. You can help these parents by encouraging them to accept and support their child’s sexual orientation or gender identity and provide parenting strategies relevant for LGBT youth. Most important of all, encourage them to seek support through organizations like PFLAG. With this support, parents can encourage healthy development in LGBT youth.

Resources for parents of LGBT youth

• The Centers for Disease Control and Prevention (CDC) has information on the health of LGBT Youth and advice on parental monitoring in general.

• The Family Acceptance Project is a project researching ways to improve parent-child relationships in LGBT Youth.

• PFLAG is an organization that provides support for families of LGBT youth.

• Lead with Love is a film about how various types of families react to their children coming out to them.

References

1. J Sex Res. 2004 Nov;41(4):329-42.

2. Aust N Z J Psychiatry. 2010 Sep;44(9):774-83.

3. Huebner D. “Leading with Love: Interventions to Support Families of Lesbian, Gay, and Bisexual Adolescents,” The Register Report, Vol. 39. National Register of Health Service Psychologists, Spring 2013.

4. J GLBT Fam Stud. 2014 Jan;10(1-2):36-57.

5. Prof Psychol Res Pr. 2008 Apr;39(2):113-21.

6. “Behaviorism: Classic Studies” (Casper, Wyo: Endeavor Books/Mountain States Litho, 2009).

7. Journal of LGBT Issues in Counseling. 2008;2(2):126-58.

8. Genet Psychol Monogr. 1967;75(1):43-88.

9. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.

10. “Parental Monitoring of Adolescents: Current Perspectives for Researchers and Practitioners” (New York: Columbia University Press, 2010).

11. AIDS Behav. 2014 Aug;18(8):1604-14.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

Two years ago, a mother of one of my patients asked me for advice. She knew that her daughter identified as lesbian, and she was fully supportive. One day, her daughter wanted to go to a sleepover at a female friend’s house. Her first reaction was to say yes, but then she had second thoughts: If her daughter were straight, and this friend were male, she would not allow her to go because of the potential for sexual activity. When she told her daughter she could not attend the sleepover, her daughter accused her of not letting her go because of her sexual orientation. And now, the dilemma: In her effort to be fair and consistent with her values, the mother is being accused of discrimination. What should she do?

Parents play an irreplaceable role in the life of any teen, especially in the lives of teens that identify as lesbian, gay, bisexual, or transgender (LGBT). But many LGBT youth face serious challenges with their parents. They face the potential of parental rejection of their sexual or gender identity. At the very worst, teens may face homelessness if they come out to homophobic parents.¹ Youth whose parents are accepting, nevertheless, are less likely to have mental health problems or engage in substance use.²

As a clinical provider for children and adolescents, caregivers will ask you for advice on how to address parenting challenges. Because LGBT youth are at risk for many adverse health outcomes, and parental support is paramount in preventing them, this is an opportunity for you to help this vulnerable population.

If parents ask you how to be supportive of their LGBT children, here are some recommendations, which are based on an intervention by colleagues at the University of Utah:³

1. Let their affection show. Receiving news that a child is LGBT can be emotionally intense for parents.⁴ Because of this emotional intensity, parents may react negatively and neglect to show their love for their child, which is what the child is seeking. Parents showing affection is the first step in supporting their LGBT child. Remind parents to tell their child that they love them no matter what.

2. Avoid rejecting behaviors. This is sometimes hard, because some forms of rejection can be quite subtle. Avoid saying anything that may indicate a negative view of LGBT people, even if it is not intended. For example, saying that something is “gay” may seem innocent enough, but it sends the message that being gay is something to be ashamed of.

3. Express their pain away from their child. Evidence shows that minimizing a child’s exposure to parental conflict and stress is associated with better coping with these devastating events.⁵ Parents should avoid telling their children that news of their sexual orientation or gender identity upsets them, as this is another form of rejecting behavior.

4. Do good before they feel good. Previous studies suggest that changes in behavior can occur even though a person may feel otherwise.⁶ Negative feelings about a child’s sexual orientation or gender identity can last months or years.⁷ It’s okay to have these feelings, but showing support such as telling their child how they still love them can ultimately lead to acceptance.

Although it is important for parents to accept their child, it is only half the battle. If you remember Baumrind’s theory on parenting, there are two sides of parenting. The first side involves parents showing their affection, love, and support for their children, which I described earlier. The other side involves managing a child’s behaviors, whether parents create an environment that makes it difficult to engage in behaviors they disapprove of or teach their children how to make the right decision.⁸ Many LGBT youth engage in risky behaviors because it’s a way of coping in a homophobic environment. The parents’ job is to teach their children healthier coping strategies.

Research on this aspect of parenting in LGBT youth is still at its infancy, and some of it is not reassuring. One important behavior, parental monitoring, which is “a set of correlated parenting behaviors involving attention to and tracking of the child’s whereabouts, activities, and adaptations,”⁹ can prevent conduct disorders, substance use, and mental health problems in the typical teenager.¹⁰ Unfortunately, we don’t find the same results for sexual minorities. One study suggests that parental monitoring may not prevent high-risk sexual behavior for young gay males, even if the parent is aware of the young man’s sexual orientation.¹¹

This doesn’t mean that parental monitoring isn’t helpful. This just means that parenting LGBT youth is different than parenting heterosexual youth. It’s not enough for parents to just accept their child’s sexual orientation. They also must help them make the right decisions taking into consideration the effect of stigma and discrimination on sexual minorities. There are a couple of things you can suggest to your parents to help them raise their LGBT children:

1. Be proactive. Join organizations that support parents of LGBT youth such as Parents, Families, and Friends of Lesbians and Gays (PFLAG). Also, parents must be aware of their children’s behavior. If they are acting depressed, seek help. Having depression or anxiety increases the chances of engaging in risky behaviors, so the earlier parents address this, the better.

2. Make their child know what their views are on high risk-behaviors, such as substance use or having unprotected sex. They need to communicate their expectations clearly. If parents believe that drinking alcohol before the legal age is wrong, they should clearly let their children know that.

3. Make it easier for their child to tell parents what’s going on in their lives. Parents have to gain their children’s trust, be accessible (don’t answer texts while talking to them!), and be an active listener. LGBT youth may not ask parents for advice because they feel that because their parents are straight or cisgender, their life experiences do not apply. Being a member of an organization like PLFAG can be helpful, because parents can ask other parents who have experience raising LGBT youth for advice that works.

4. If parents’ children do something wrong, they should talk to them about how their actions were risky. Children will listen to parents if they view their parenting as legitimate and fair, which can only happen if there is a strong parent-child relationship. Being supportive of a child’s sexual orientation or gender identity is key here. And for the next time, it’s always good to role-play a scenario (for example, what to do if someone tries to make them drink at a party).

Parents of LGBT youth face many challenges. You can help these parents by encouraging them to accept and support their child’s sexual orientation or gender identity and provide parenting strategies relevant for LGBT youth. Most important of all, encourage them to seek support through organizations like PFLAG. With this support, parents can encourage healthy development in LGBT youth.

Resources for parents of LGBT youth

• The Centers for Disease Control and Prevention (CDC) has information on the health of LGBT Youth and advice on parental monitoring in general.

• The Family Acceptance Project is a project researching ways to improve parent-child relationships in LGBT Youth.

• PFLAG is an organization that provides support for families of LGBT youth.

• Lead with Love is a film about how various types of families react to their children coming out to them.

References

1. J Sex Res. 2004 Nov;41(4):329-42.

2. Aust N Z J Psychiatry. 2010 Sep;44(9):774-83.

3. Huebner D. “Leading with Love: Interventions to Support Families of Lesbian, Gay, and Bisexual Adolescents,” The Register Report, Vol. 39. National Register of Health Service Psychologists, Spring 2013.

4. J GLBT Fam Stud. 2014 Jan;10(1-2):36-57.

5. Prof Psychol Res Pr. 2008 Apr;39(2):113-21.

6. “Behaviorism: Classic Studies” (Casper, Wyo: Endeavor Books/Mountain States Litho, 2009).

7. Journal of LGBT Issues in Counseling. 2008;2(2):126-58.

8. Genet Psychol Monogr. 1967;75(1):43-88.

9. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.

10. “Parental Monitoring of Adolescents: Current Perspectives for Researchers and Practitioners” (New York: Columbia University Press, 2010).

11. AIDS Behav. 2014 Aug;18(8):1604-14.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

I am a relatively young physician. When I started medical school 10 years ago, I thought that most medical school campuses would be fairly progressive. This was not the case for me.

My school did not have a nondiscrimination policy on sexual orientation or gender identity at the time, nor do I recall any lectures about this patient population. So during my first year of medical school, I embarked on a mission to educate both my classmates and the faculty about sexual orientation, gender identity, and related health disparities. My fellow classmates and the administration received my efforts warmly; nevertheless, this effort to educate was an incredible challenge for me. Surely other medical school campuses were already discussing the importance of sexuality and gender identity, I thought.

Fast forward to the year 2011. A study in JAMA found that many medical schools fall short in teaching the next generation of physicians about lesbian, gay, bisexual, and transgender (LGBT) health (JAMA. 2011;306[9]:971-7).

Things may have improved for LGBT people, but the world of medicine has yet to catch up. If LGBT medical education is lacking today, imagine how lacking it was for those who went to medical school decades ago. It is my hope that with this new column, we as a medical community can make up for lost time.

Why should physicians, especially pediatricians, care about LGBT health? Although LGBT youth comprise less than 10% of the adolescent population, they have a disproportionate share of health problems compared with their heterosexual peers. LGBT youth are three times as likely to attempt suicide and almost two times as likely to abuse alcohol and drugs compared with heterosexual youth. Among homeless teens in the United States, a whopping 40% are LGBT. HIV still plagues young gay males – especially those of color – and young gay and bisexual women experience an inordinate amount of dating violence from both men and women. Most appalling of all, every 3 days, a transgender person is murdered. These sobering statistics highlight the impact sexual orientation and gender identity have on health.

Why do LGBT youth experience such enormous health problems? A rich body of evidence points to stigma and discrimination as a likely cause. We are familiar with stories of how LGBT youth are kicked out of their homes after coming out to their parents or how male teens suffered bullying for being perceived as “too feminine.” Nonetheless, we tend to ignore the more subtle ways LGBT youth experience stigma and discrimination through our heterosexist language and behavior. Although we could dismiss the phrase “that’s so gay” as just another variation of “that’s so dumb,” an LGBT teen might think “if something is that dumb, then so am I.”

My fellow columnists and I hope that this column will help you get to know a very vulnerable, yet special, population. We will ask you to rethink what you have learned about sexuality and gender. Here, we will start with the basics.

What is the difference between sex and gender?

Sex is the biological distinction between male and female that is determined chromosomally (XX versus XY, although there are variations) and phenotypically, such as organs like the penis or vagina. Gender is a range of characteristics that a culture assigns as typically male and female, which encompasses both anatomy and behaviors. For example, an individual assigned as male because he was born with a penis is also expected to be proactive, a problem solver, stoic, and the breadwinner of the family. Although we’d like to believe that there are clear distinctions between the two solely on the basis of anatomy, we often see many people diverge from behaviors that are typically assigned to a gender. In modern day U.S. society, there are an increasing number of men who stay home to take care of their children – a typically female role. In other words, gender is a spectrum ranging from the very masculine to the very feminine and everything else in between.

What is gender identity?

Gender identity is our own sense of maleness or femaleness. This identity can be based on a variety of factors, including the sex organ one is born with and the culture one is raised in. It also is possible for some people to feel that they do not fit neatly into male or female categories. At the end of the day, only you can determine your gender identity, despite beliefs and attitudes in society about which appearances and behaviors are stereotypically male or female.

Transgender people are individuals who experience a mismatch between their gender identity and their assigned sex at birth. The word “trans” is Latin for “the other side,” highlighting the discrepancy between one’s gender identity and assigned sex. In contrast, people who identify as their assigned sex would be called cisgender. The word “cis” is Latin for “the same side.” A transgender male is someone who was assigned female at birth, but identifies as a male, whereas a transgender female is someone who was assigned male at birth, but identifies as a female. You also may also hear the terms “FTM” (female to male) and “MTF” (male to female) to describe transgender males and females, respectively.

What is sexual orientation?

Sexual orientation refers to our pattern of emotional and/or physical attraction to people who are the same or the opposite gender. The most common in this society is heterosexual, where one finds the opposite gender attractive. Those who identify as gay or lesbian find the same gender attractive. A person who identifies as bisexual finds both genders attractive. There are other sexual orientations that are not as commonly known. Someone who is pansexual is attracted to any sex or gender identity. Asexuals are individuals who don’t find anyone sexually attractive, but could be attracted to someone romantically or emotionally irrespective of sex or gender.

Just as gender is fluid, so is sexuality. Alfred Kinsey, a well-known sexologist, introduced the concept of sexual fluidity with the Kinsey Scale. With this scale, people rate themselves on how attracted they are to each sex, ranging from 0 – meaning exclusively attracted to the opposite sex – to 3 – equally attracted to both sexes – to 6 – exclusively attracted to the same sex. It is possible to move along the spectrum in either direction over time or stay in one place. It is also possible for our sexual identity (i.e. lesbian, gay, bisexual) and sexual behavior (i.e. whom we are having sex with) to not perfectly overlap; attraction is complex. Finally, people often confuse gender identity and sexual orientation. These are two separate concepts and not dependent on each other. For example, someone who was assigned female at birth but now identifies as male can still be attracted to men.

This primer is by no means complete or comprehensive and runs the risk of being oversimplistic. Nevertheless, I hope it will get you thinking about the nature of sexuality and gender identity and how they affect health. In the next couple of months, you will read more on the complexities of sexuality and gender identity, advice on how to talk to your patients about these topics, how to make your clinic a safe place for LGBT youth, the transition process for transgender youth, and much more. I encourage you stick around to learn how you can help this vulnerable, but amazing, group of young people. Until next time …

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh.

I am a relatively young physician. When I started medical school 10 years ago, I thought that most medical school campuses would be fairly progressive. This was not the case for me.

My school did not have a nondiscrimination policy on sexual orientation or gender identity at the time, nor do I recall any lectures about this patient population. So during my first year of medical school, I embarked on a mission to educate both my classmates and the faculty about sexual orientation, gender identity, and related health disparities. My fellow classmates and the administration received my efforts warmly; nevertheless, this effort to educate was an incredible challenge for me. Surely other medical school campuses were already discussing the importance of sexuality and gender identity, I thought.

Fast forward to the year 2011. A study in JAMA found that many medical schools fall short in teaching the next generation of physicians about lesbian, gay, bisexual, and transgender (LGBT) health (JAMA. 2011;306[9]:971-7).

Things may have improved for LGBT people, but the world of medicine has yet to catch up. If LGBT medical education is lacking today, imagine how lacking it was for those who went to medical school decades ago. It is my hope that with this new column, we as a medical community can make up for lost time.

Why should physicians, especially pediatricians, care about LGBT health? Although LGBT youth comprise less than 10% of the adolescent population, they have a disproportionate share of health problems compared with their heterosexual peers. LGBT youth are three times as likely to attempt suicide and almost two times as likely to abuse alcohol and drugs compared with heterosexual youth. Among homeless teens in the United States, a whopping 40% are LGBT. HIV still plagues young gay males – especially those of color – and young gay and bisexual women experience an inordinate amount of dating violence from both men and women. Most appalling of all, every 3 days, a transgender person is murdered. These sobering statistics highlight the impact sexual orientation and gender identity have on health.

Why do LGBT youth experience such enormous health problems? A rich body of evidence points to stigma and discrimination as a likely cause. We are familiar with stories of how LGBT youth are kicked out of their homes after coming out to their parents or how male teens suffered bullying for being perceived as “too feminine.” Nonetheless, we tend to ignore the more subtle ways LGBT youth experience stigma and discrimination through our heterosexist language and behavior. Although we could dismiss the phrase “that’s so gay” as just another variation of “that’s so dumb,” an LGBT teen might think “if something is that dumb, then so am I.”

My fellow columnists and I hope that this column will help you get to know a very vulnerable, yet special, population. We will ask you to rethink what you have learned about sexuality and gender. Here, we will start with the basics.

What is the difference between sex and gender?

Sex is the biological distinction between male and female that is determined chromosomally (XX versus XY, although there are variations) and phenotypically, such as organs like the penis or vagina. Gender is a range of characteristics that a culture assigns as typically male and female, which encompasses both anatomy and behaviors. For example, an individual assigned as male because he was born with a penis is also expected to be proactive, a problem solver, stoic, and the breadwinner of the family. Although we’d like to believe that there are clear distinctions between the two solely on the basis of anatomy, we often see many people diverge from behaviors that are typically assigned to a gender. In modern day U.S. society, there are an increasing number of men who stay home to take care of their children – a typically female role. In other words, gender is a spectrum ranging from the very masculine to the very feminine and everything else in between.

What is gender identity?

Gender identity is our own sense of maleness or femaleness. This identity can be based on a variety of factors, including the sex organ one is born with and the culture one is raised in. It also is possible for some people to feel that they do not fit neatly into male or female categories. At the end of the day, only you can determine your gender identity, despite beliefs and attitudes in society about which appearances and behaviors are stereotypically male or female.

Transgender people are individuals who experience a mismatch between their gender identity and their assigned sex at birth. The word “trans” is Latin for “the other side,” highlighting the discrepancy between one’s gender identity and assigned sex. In contrast, people who identify as their assigned sex would be called cisgender. The word “cis” is Latin for “the same side.” A transgender male is someone who was assigned female at birth, but identifies as a male, whereas a transgender female is someone who was assigned male at birth, but identifies as a female. You also may also hear the terms “FTM” (female to male) and “MTF” (male to female) to describe transgender males and females, respectively.

What is sexual orientation?

Sexual orientation refers to our pattern of emotional and/or physical attraction to people who are the same or the opposite gender. The most common in this society is heterosexual, where one finds the opposite gender attractive. Those who identify as gay or lesbian find the same gender attractive. A person who identifies as bisexual finds both genders attractive. There are other sexual orientations that are not as commonly known. Someone who is pansexual is attracted to any sex or gender identity. Asexuals are individuals who don’t find anyone sexually attractive, but could be attracted to someone romantically or emotionally irrespective of sex or gender.

Just as gender is fluid, so is sexuality. Alfred Kinsey, a well-known sexologist, introduced the concept of sexual fluidity with the Kinsey Scale. With this scale, people rate themselves on how attracted they are to each sex, ranging from 0 – meaning exclusively attracted to the opposite sex – to 3 – equally attracted to both sexes – to 6 – exclusively attracted to the same sex. It is possible to move along the spectrum in either direction over time or stay in one place. It is also possible for our sexual identity (i.e. lesbian, gay, bisexual) and sexual behavior (i.e. whom we are having sex with) to not perfectly overlap; attraction is complex. Finally, people often confuse gender identity and sexual orientation. These are two separate concepts and not dependent on each other. For example, someone who was assigned female at birth but now identifies as male can still be attracted to men.

This primer is by no means complete or comprehensive and runs the risk of being oversimplistic. Nevertheless, I hope it will get you thinking about the nature of sexuality and gender identity and how they affect health. In the next couple of months, you will read more on the complexities of sexuality and gender identity, advice on how to talk to your patients about these topics, how to make your clinic a safe place for LGBT youth, the transition process for transgender youth, and much more. I encourage you stick around to learn how you can help this vulnerable, but amazing, group of young people. Until next time …

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh.

I am a relatively young physician. When I started medical school 10 years ago, I thought that most medical school campuses would be fairly progressive. This was not the case for me.

My school did not have a nondiscrimination policy on sexual orientation or gender identity at the time, nor do I recall any lectures about this patient population. So during my first year of medical school, I embarked on a mission to educate both my classmates and the faculty about sexual orientation, gender identity, and related health disparities. My fellow classmates and the administration received my efforts warmly; nevertheless, this effort to educate was an incredible challenge for me. Surely other medical school campuses were already discussing the importance of sexuality and gender identity, I thought.

Fast forward to the year 2011. A study in JAMA found that many medical schools fall short in teaching the next generation of physicians about lesbian, gay, bisexual, and transgender (LGBT) health (JAMA. 2011;306[9]:971-7).

Things may have improved for LGBT people, but the world of medicine has yet to catch up. If LGBT medical education is lacking today, imagine how lacking it was for those who went to medical school decades ago. It is my hope that with this new column, we as a medical community can make up for lost time.

Why should physicians, especially pediatricians, care about LGBT health? Although LGBT youth comprise less than 10% of the adolescent population, they have a disproportionate share of health problems compared with their heterosexual peers. LGBT youth are three times as likely to attempt suicide and almost two times as likely to abuse alcohol and drugs compared with heterosexual youth. Among homeless teens in the United States, a whopping 40% are LGBT. HIV still plagues young gay males – especially those of color – and young gay and bisexual women experience an inordinate amount of dating violence from both men and women. Most appalling of all, every 3 days, a transgender person is murdered. These sobering statistics highlight the impact sexual orientation and gender identity have on health.

Why do LGBT youth experience such enormous health problems? A rich body of evidence points to stigma and discrimination as a likely cause. We are familiar with stories of how LGBT youth are kicked out of their homes after coming out to their parents or how male teens suffered bullying for being perceived as “too feminine.” Nonetheless, we tend to ignore the more subtle ways LGBT youth experience stigma and discrimination through our heterosexist language and behavior. Although we could dismiss the phrase “that’s so gay” as just another variation of “that’s so dumb,” an LGBT teen might think “if something is that dumb, then so am I.”

My fellow columnists and I hope that this column will help you get to know a very vulnerable, yet special, population. We will ask you to rethink what you have learned about sexuality and gender. Here, we will start with the basics.

What is the difference between sex and gender?

Sex is the biological distinction between male and female that is determined chromosomally (XX versus XY, although there are variations) and phenotypically, such as organs like the penis or vagina. Gender is a range of characteristics that a culture assigns as typically male and female, which encompasses both anatomy and behaviors. For example, an individual assigned as male because he was born with a penis is also expected to be proactive, a problem solver, stoic, and the breadwinner of the family. Although we’d like to believe that there are clear distinctions between the two solely on the basis of anatomy, we often see many people diverge from behaviors that are typically assigned to a gender. In modern day U.S. society, there are an increasing number of men who stay home to take care of their children – a typically female role. In other words, gender is a spectrum ranging from the very masculine to the very feminine and everything else in between.

What is gender identity?

Gender identity is our own sense of maleness or femaleness. This identity can be based on a variety of factors, including the sex organ one is born with and the culture one is raised in. It also is possible for some people to feel that they do not fit neatly into male or female categories. At the end of the day, only you can determine your gender identity, despite beliefs and attitudes in society about which appearances and behaviors are stereotypically male or female.

Transgender people are individuals who experience a mismatch between their gender identity and their assigned sex at birth. The word “trans” is Latin for “the other side,” highlighting the discrepancy between one’s gender identity and assigned sex. In contrast, people who identify as their assigned sex would be called cisgender. The word “cis” is Latin for “the same side.” A transgender male is someone who was assigned female at birth, but identifies as a male, whereas a transgender female is someone who was assigned male at birth, but identifies as a female. You also may also hear the terms “FTM” (female to male) and “MTF” (male to female) to describe transgender males and females, respectively.

What is sexual orientation?

Sexual orientation refers to our pattern of emotional and/or physical attraction to people who are the same or the opposite gender. The most common in this society is heterosexual, where one finds the opposite gender attractive. Those who identify as gay or lesbian find the same gender attractive. A person who identifies as bisexual finds both genders attractive. There are other sexual orientations that are not as commonly known. Someone who is pansexual is attracted to any sex or gender identity. Asexuals are individuals who don’t find anyone sexually attractive, but could be attracted to someone romantically or emotionally irrespective of sex or gender.

Just as gender is fluid, so is sexuality. Alfred Kinsey, a well-known sexologist, introduced the concept of sexual fluidity with the Kinsey Scale. With this scale, people rate themselves on how attracted they are to each sex, ranging from 0 – meaning exclusively attracted to the opposite sex – to 3 – equally attracted to both sexes – to 6 – exclusively attracted to the same sex. It is possible to move along the spectrum in either direction over time or stay in one place. It is also possible for our sexual identity (i.e. lesbian, gay, bisexual) and sexual behavior (i.e. whom we are having sex with) to not perfectly overlap; attraction is complex. Finally, people often confuse gender identity and sexual orientation. These are two separate concepts and not dependent on each other. For example, someone who was assigned female at birth but now identifies as male can still be attracted to men.

This primer is by no means complete or comprehensive and runs the risk of being oversimplistic. Nevertheless, I hope it will get you thinking about the nature of sexuality and gender identity and how they affect health. In the next couple of months, you will read more on the complexities of sexuality and gender identity, advice on how to talk to your patients about these topics, how to make your clinic a safe place for LGBT youth, the transition process for transgender youth, and much more. I encourage you stick around to learn how you can help this vulnerable, but amazing, group of young people. Until next time …

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh.