User login
Preexposure prophylaxis among LGBT youth
Every prevention effort or treatment has its own risks. Gynecologists must consider the risk for blood clots from using estrogen-containing oral contraceptives versus the risk of blood clots from pregnancy. Endocrinologists must weigh the risk of decreased bone mineral density versus premature closure of growth plates when starting pubertal blockers for children suffering from precocious puberty. Psychologists and primary care providers must consider the risk for increased suicidal thoughts while on selective serotonin reuptake inhibitors versus the risk of completed suicide if the depression remains untreated.
In the United States alone, 22% of HIV infections occur in people aged 13-24 years. Among those with HIV infection, 81% are young men who have sex with men (MSM).1 Among those new infections, young MSM of color are nearly four times as likely to have HIV, compared with white young MSM.2 Moreover, the incidence of HIV infection among transgender individuals is three times higher than the national average.3
What further hampers public health prevention efforts is the stigma and discrimination LGBT youth face in trying to prevent HIV infections: 84% of those aged 15-24 years report recognizing stigma around HIV in the United States.4 In addition, black MSM were more likely than other MSMs to report this kind of stigma.5 And it isn’t enough that LGBT youth have to face stigma and discrimination. In fact, because of it, they often face serious financial challenges. It is estimated that 50% of homeless youth identify as LGBT, and 40% of them were forced out of their homes because of their sexual orientation or gender identity.6 Also, transgender youth have difficulty finding employment because of their gender identity.7 A combination of homelessness or chronic unemployment has driven many LGBT youth to survival sex or sex for money, which puts them at higher risk for HIV infection.7,8 The risk for HIV infection is so high that we should be using all available resources, including PrEP, to address these profound health disparities.
Studies, however, are forthcoming. One study by Hosek et al. that was published in September suggested that PrEP among adolescents can be safe and well tolerated, may not increase the rate of high-risk sexual behaviors, and may not increase the risk of other STDs such as gonorrhea and chlamydia. It must be noted, however, that incidence of HIV was fairly high – the HIV seroconversion rate was 6.4 per 100 person-years. Nevertheless, researchers found the rate of HIV seroconversion was higher among those with lower levels of Truvada in their bodies, compared with the seroconversion rate in those with higher levels of the medication. This suggests that adherence is key in using PrEP to prevent HIV infection.10 Although far from definitive, this small study provides some solid evidence that PrEP is safe and effective in preventing HIV among LGBT youth. More studies that will eventually support its effectiveness and safety are on the way.11
Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].
Resource
CDC website on PrEP: https://www.cdc.gov/hiv/risk/prep/index.html, with provider guidelines.
References
1. Centers for Disease Control and Prevention. HIV Among Youth fact sheet, April 2017.
2. Centers for Disease Control and Prevention. HIV Surveillance Report, 2015; vol. 27.
3. Centers for Disease Control and Prevention. HIV Among Transgender People.
4. Kaiser Family Foundation. National survey of teens and young adults on HIV/AIDS, Nov. 1, 2012. .
5. J Acquir Immune Defic Syndr. 2016;73(5):547-55.
6. Serving our youth: Findings from a national survey of services providers working with lesbian, gay, bisexual and transgender youth who are homeless or at risk of becoming homeless (The Williams Institute with True Colors and The Palette Fund, 2012).
7. Injustice at every turn: A report of the national transgender discrimination survey (National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).
8. J Acquir Immune Defic Syndr. 2010 Apr;53(5):661-4.
9. Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States: A clinical practice guideline, 2014.
10. JAMA Pediatr. 2017;171(11):1063-71.
11. J Int AIDS Soc. 2016;19. doi: 10.7448/IAS.19.7.21107.
Every prevention effort or treatment has its own risks. Gynecologists must consider the risk for blood clots from using estrogen-containing oral contraceptives versus the risk of blood clots from pregnancy. Endocrinologists must weigh the risk of decreased bone mineral density versus premature closure of growth plates when starting pubertal blockers for children suffering from precocious puberty. Psychologists and primary care providers must consider the risk for increased suicidal thoughts while on selective serotonin reuptake inhibitors versus the risk of completed suicide if the depression remains untreated.
In the United States alone, 22% of HIV infections occur in people aged 13-24 years. Among those with HIV infection, 81% are young men who have sex with men (MSM).1 Among those new infections, young MSM of color are nearly four times as likely to have HIV, compared with white young MSM.2 Moreover, the incidence of HIV infection among transgender individuals is three times higher than the national average.3
What further hampers public health prevention efforts is the stigma and discrimination LGBT youth face in trying to prevent HIV infections: 84% of those aged 15-24 years report recognizing stigma around HIV in the United States.4 In addition, black MSM were more likely than other MSMs to report this kind of stigma.5 And it isn’t enough that LGBT youth have to face stigma and discrimination. In fact, because of it, they often face serious financial challenges. It is estimated that 50% of homeless youth identify as LGBT, and 40% of them were forced out of their homes because of their sexual orientation or gender identity.6 Also, transgender youth have difficulty finding employment because of their gender identity.7 A combination of homelessness or chronic unemployment has driven many LGBT youth to survival sex or sex for money, which puts them at higher risk for HIV infection.7,8 The risk for HIV infection is so high that we should be using all available resources, including PrEP, to address these profound health disparities.
Studies, however, are forthcoming. One study by Hosek et al. that was published in September suggested that PrEP among adolescents can be safe and well tolerated, may not increase the rate of high-risk sexual behaviors, and may not increase the risk of other STDs such as gonorrhea and chlamydia. It must be noted, however, that incidence of HIV was fairly high – the HIV seroconversion rate was 6.4 per 100 person-years. Nevertheless, researchers found the rate of HIV seroconversion was higher among those with lower levels of Truvada in their bodies, compared with the seroconversion rate in those with higher levels of the medication. This suggests that adherence is key in using PrEP to prevent HIV infection.10 Although far from definitive, this small study provides some solid evidence that PrEP is safe and effective in preventing HIV among LGBT youth. More studies that will eventually support its effectiveness and safety are on the way.11
Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].
Resource
CDC website on PrEP: https://www.cdc.gov/hiv/risk/prep/index.html, with provider guidelines.
References
1. Centers for Disease Control and Prevention. HIV Among Youth fact sheet, April 2017.
2. Centers for Disease Control and Prevention. HIV Surveillance Report, 2015; vol. 27.
3. Centers for Disease Control and Prevention. HIV Among Transgender People.
4. Kaiser Family Foundation. National survey of teens and young adults on HIV/AIDS, Nov. 1, 2012. .
5. J Acquir Immune Defic Syndr. 2016;73(5):547-55.
6. Serving our youth: Findings from a national survey of services providers working with lesbian, gay, bisexual and transgender youth who are homeless or at risk of becoming homeless (The Williams Institute with True Colors and The Palette Fund, 2012).
7. Injustice at every turn: A report of the national transgender discrimination survey (National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).
8. J Acquir Immune Defic Syndr. 2010 Apr;53(5):661-4.
9. Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States: A clinical practice guideline, 2014.
10. JAMA Pediatr. 2017;171(11):1063-71.
11. J Int AIDS Soc. 2016;19. doi: 10.7448/IAS.19.7.21107.
Every prevention effort or treatment has its own risks. Gynecologists must consider the risk for blood clots from using estrogen-containing oral contraceptives versus the risk of blood clots from pregnancy. Endocrinologists must weigh the risk of decreased bone mineral density versus premature closure of growth plates when starting pubertal blockers for children suffering from precocious puberty. Psychologists and primary care providers must consider the risk for increased suicidal thoughts while on selective serotonin reuptake inhibitors versus the risk of completed suicide if the depression remains untreated.
In the United States alone, 22% of HIV infections occur in people aged 13-24 years. Among those with HIV infection, 81% are young men who have sex with men (MSM).1 Among those new infections, young MSM of color are nearly four times as likely to have HIV, compared with white young MSM.2 Moreover, the incidence of HIV infection among transgender individuals is three times higher than the national average.3
What further hampers public health prevention efforts is the stigma and discrimination LGBT youth face in trying to prevent HIV infections: 84% of those aged 15-24 years report recognizing stigma around HIV in the United States.4 In addition, black MSM were more likely than other MSMs to report this kind of stigma.5 And it isn’t enough that LGBT youth have to face stigma and discrimination. In fact, because of it, they often face serious financial challenges. It is estimated that 50% of homeless youth identify as LGBT, and 40% of them were forced out of their homes because of their sexual orientation or gender identity.6 Also, transgender youth have difficulty finding employment because of their gender identity.7 A combination of homelessness or chronic unemployment has driven many LGBT youth to survival sex or sex for money, which puts them at higher risk for HIV infection.7,8 The risk for HIV infection is so high that we should be using all available resources, including PrEP, to address these profound health disparities.
Studies, however, are forthcoming. One study by Hosek et al. that was published in September suggested that PrEP among adolescents can be safe and well tolerated, may not increase the rate of high-risk sexual behaviors, and may not increase the risk of other STDs such as gonorrhea and chlamydia. It must be noted, however, that incidence of HIV was fairly high – the HIV seroconversion rate was 6.4 per 100 person-years. Nevertheless, researchers found the rate of HIV seroconversion was higher among those with lower levels of Truvada in their bodies, compared with the seroconversion rate in those with higher levels of the medication. This suggests that adherence is key in using PrEP to prevent HIV infection.10 Although far from definitive, this small study provides some solid evidence that PrEP is safe and effective in preventing HIV among LGBT youth. More studies that will eventually support its effectiveness and safety are on the way.11
Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].
Resource
CDC website on PrEP: https://www.cdc.gov/hiv/risk/prep/index.html, with provider guidelines.
References
1. Centers for Disease Control and Prevention. HIV Among Youth fact sheet, April 2017.
2. Centers for Disease Control and Prevention. HIV Surveillance Report, 2015; vol. 27.
3. Centers for Disease Control and Prevention. HIV Among Transgender People.
4. Kaiser Family Foundation. National survey of teens and young adults on HIV/AIDS, Nov. 1, 2012. .
5. J Acquir Immune Defic Syndr. 2016;73(5):547-55.
6. Serving our youth: Findings from a national survey of services providers working with lesbian, gay, bisexual and transgender youth who are homeless or at risk of becoming homeless (The Williams Institute with True Colors and The Palette Fund, 2012).
7. Injustice at every turn: A report of the national transgender discrimination survey (National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011).
8. J Acquir Immune Defic Syndr. 2010 Apr;53(5):661-4.
9. Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States: A clinical practice guideline, 2014.
10. JAMA Pediatr. 2017;171(11):1063-71.
11. J Int AIDS Soc. 2016;19. doi: 10.7448/IAS.19.7.21107.
Eating disorders over the holidays
For many, the holiday season is a time to celebrate, relax, and enjoy the company of family. Much of this celebrating centers on eating and food. Historically, eating disorders were associated with young, straight, cisgender, white females. Data collected over the past 15 years suggest that eating disorders can affect youth of all ethnicities and genders.
Below are some tips from the National Eating Disorder Association that may be helpful for youth struggling with an eating disorder over the holiday season:
• Eat regularly and in a consistent pattern. Avoid skipping meals or restricting intake in preparation for a holiday meal.
• Discuss any anticipated struggles around food or family with your parents, therapist, health care provider, dietitian, or other members of your support group. This can allow you to plan ahead for any challenges that may arise, and could prevent potential negative or harmful coping behaviors
• Consider choosing a loved one to be your “reality check” with food, to either help fix a plate for you or to give you sound feedback on the food portion sizes you make for yourself.
• Have a game plan before you go to a holiday event. Know who your support people are and how you’ll recognize when it may be time to make a quick exit and get connected with needed support.
• Avoid overextending yourself. A lower stress level can decrease the need to turn to eating-disordered behaviors or other unhelpful coping strategies.
• Work on being flexible in your thoughts. Learn to be flexible when setting guidelines for yourself and expectations of yourself and others. Strive to be flexible in what you can eat during the holidays. Take a holiday from self-imposed criticism, rigidity, and perfectionism.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].
Resources
National Eating Disorders Association: www.nationaleatingdisorders.org
“Body image and eating disorders among lesbian, gay, bisexual, and transgender youth” (Pediatr Clin North Am. 2016 Dec;63[6]:1079-90.
References
1. Prev Chronic Dis. 2008 Oct;5(4):A114.
2. Arch Gen Psychiatry. 2011 Jul;68(7):714-23.
3. Pediatr Clin North Am. 2016 Dec;63(6):1079-90.
4. Curr Psychiatry Rep. 2012 Aug;14(4):391-7.
5. J Adolesc Health. 2015 Aug;57(2):144-9.
6. Am J Public Health. 2013 Feb;103(2):e16-22.
7. J Adolesc Health. 2009 Sep;45(3):238-45.
For many, the holiday season is a time to celebrate, relax, and enjoy the company of family. Much of this celebrating centers on eating and food. Historically, eating disorders were associated with young, straight, cisgender, white females. Data collected over the past 15 years suggest that eating disorders can affect youth of all ethnicities and genders.
Below are some tips from the National Eating Disorder Association that may be helpful for youth struggling with an eating disorder over the holiday season:
• Eat regularly and in a consistent pattern. Avoid skipping meals or restricting intake in preparation for a holiday meal.
• Discuss any anticipated struggles around food or family with your parents, therapist, health care provider, dietitian, or other members of your support group. This can allow you to plan ahead for any challenges that may arise, and could prevent potential negative or harmful coping behaviors
• Consider choosing a loved one to be your “reality check” with food, to either help fix a plate for you or to give you sound feedback on the food portion sizes you make for yourself.
• Have a game plan before you go to a holiday event. Know who your support people are and how you’ll recognize when it may be time to make a quick exit and get connected with needed support.
• Avoid overextending yourself. A lower stress level can decrease the need to turn to eating-disordered behaviors or other unhelpful coping strategies.
• Work on being flexible in your thoughts. Learn to be flexible when setting guidelines for yourself and expectations of yourself and others. Strive to be flexible in what you can eat during the holidays. Take a holiday from self-imposed criticism, rigidity, and perfectionism.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].
Resources
National Eating Disorders Association: www.nationaleatingdisorders.org
“Body image and eating disorders among lesbian, gay, bisexual, and transgender youth” (Pediatr Clin North Am. 2016 Dec;63[6]:1079-90.
References
1. Prev Chronic Dis. 2008 Oct;5(4):A114.
2. Arch Gen Psychiatry. 2011 Jul;68(7):714-23.
3. Pediatr Clin North Am. 2016 Dec;63(6):1079-90.
4. Curr Psychiatry Rep. 2012 Aug;14(4):391-7.
5. J Adolesc Health. 2015 Aug;57(2):144-9.
6. Am J Public Health. 2013 Feb;103(2):e16-22.
7. J Adolesc Health. 2009 Sep;45(3):238-45.
For many, the holiday season is a time to celebrate, relax, and enjoy the company of family. Much of this celebrating centers on eating and food. Historically, eating disorders were associated with young, straight, cisgender, white females. Data collected over the past 15 years suggest that eating disorders can affect youth of all ethnicities and genders.
Below are some tips from the National Eating Disorder Association that may be helpful for youth struggling with an eating disorder over the holiday season:
• Eat regularly and in a consistent pattern. Avoid skipping meals or restricting intake in preparation for a holiday meal.
• Discuss any anticipated struggles around food or family with your parents, therapist, health care provider, dietitian, or other members of your support group. This can allow you to plan ahead for any challenges that may arise, and could prevent potential negative or harmful coping behaviors
• Consider choosing a loved one to be your “reality check” with food, to either help fix a plate for you or to give you sound feedback on the food portion sizes you make for yourself.
• Have a game plan before you go to a holiday event. Know who your support people are and how you’ll recognize when it may be time to make a quick exit and get connected with needed support.
• Avoid overextending yourself. A lower stress level can decrease the need to turn to eating-disordered behaviors or other unhelpful coping strategies.
• Work on being flexible in your thoughts. Learn to be flexible when setting guidelines for yourself and expectations of yourself and others. Strive to be flexible in what you can eat during the holidays. Take a holiday from self-imposed criticism, rigidity, and perfectionism.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at [email protected].
Resources
National Eating Disorders Association: www.nationaleatingdisorders.org
“Body image and eating disorders among lesbian, gay, bisexual, and transgender youth” (Pediatr Clin North Am. 2016 Dec;63[6]:1079-90.
References
1. Prev Chronic Dis. 2008 Oct;5(4):A114.
2. Arch Gen Psychiatry. 2011 Jul;68(7):714-23.
3. Pediatr Clin North Am. 2016 Dec;63(6):1079-90.
4. Curr Psychiatry Rep. 2012 Aug;14(4):391-7.
5. J Adolesc Health. 2015 Aug;57(2):144-9.
6. Am J Public Health. 2013 Feb;103(2):e16-22.
7. J Adolesc Health. 2009 Sep;45(3):238-45.
Inclusive sexual health counseling and care
Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.1 Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.
Obtaining a sexual history
1. Clearly explain the reasons for asking sexually explicit questions.
TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.
2. Ensure confidentiality.
When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.2,3 The Guttmacher Institute provides information about minors’ consent law in each state.4
3. Do not assume identity equals behavior.
Here are some sexual health questions you need to ask:
- Who are you attracted to? What is/are the gender(s) of your partner(s)?
- Have you ever had anal, genital, or oral sex? If yes:
Do you give, receive, or both?
When was the last time you had sex?
How many partners have you had in past 6 months?
Do you use barrier protection most of the time, some of the time, always, or never?
Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?
- Have you ever been forced/coerced into having sex?
Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.
4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit
Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.5 For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.6
Physical exam
Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.
Sexual health counseling
Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.9 In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.
Email her at [email protected].
References
1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, in Center of Excellence for Transgender Health, Department of Family and Community Medicine, 2nd ed. (San Francisco: University of California, 2016).
2. Pediatrics. 2008. doi: 10.1542/peds.2008-0694.
3. J Adol Health. 2004;35:160-7.
4. An Overview of Minors’ Consent Law: State Laws and Policies. 2017, by the Guttmacher Institute.
5. Eur J Endocrinol. 2011 Aug;165(2):331-7.
6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
7. Sex Roles. 2013 Jun 1;68(11-12):675-89.
8. J Midwifery Womens Health. 2008 Jul-Aug;53(4):331-7.
9. “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,” 2nd ed. (Philadelphia: American College of Physicians Press, 2008).
Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.1 Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.
Obtaining a sexual history
1. Clearly explain the reasons for asking sexually explicit questions.
TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.
2. Ensure confidentiality.
When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.2,3 The Guttmacher Institute provides information about minors’ consent law in each state.4
3. Do not assume identity equals behavior.
Here are some sexual health questions you need to ask:
- Who are you attracted to? What is/are the gender(s) of your partner(s)?
- Have you ever had anal, genital, or oral sex? If yes:
Do you give, receive, or both?
When was the last time you had sex?
How many partners have you had in past 6 months?
Do you use barrier protection most of the time, some of the time, always, or never?
Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?
- Have you ever been forced/coerced into having sex?
Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.
4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit
Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.5 For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.6
Physical exam
Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.
Sexual health counseling
Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.9 In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.
Email her at [email protected].
References
1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, in Center of Excellence for Transgender Health, Department of Family and Community Medicine, 2nd ed. (San Francisco: University of California, 2016).
2. Pediatrics. 2008. doi: 10.1542/peds.2008-0694.
3. J Adol Health. 2004;35:160-7.
4. An Overview of Minors’ Consent Law: State Laws and Policies. 2017, by the Guttmacher Institute.
5. Eur J Endocrinol. 2011 Aug;165(2):331-7.
6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
7. Sex Roles. 2013 Jun 1;68(11-12):675-89.
8. J Midwifery Womens Health. 2008 Jul-Aug;53(4):331-7.
9. “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,” 2nd ed. (Philadelphia: American College of Physicians Press, 2008).
Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.1 Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.
Obtaining a sexual history
1. Clearly explain the reasons for asking sexually explicit questions.
TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.
2. Ensure confidentiality.
When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.2,3 The Guttmacher Institute provides information about minors’ consent law in each state.4
3. Do not assume identity equals behavior.
Here are some sexual health questions you need to ask:
- Who are you attracted to? What is/are the gender(s) of your partner(s)?
- Have you ever had anal, genital, or oral sex? If yes:
Do you give, receive, or both?
When was the last time you had sex?
How many partners have you had in past 6 months?
Do you use barrier protection most of the time, some of the time, always, or never?
Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?
- Have you ever been forced/coerced into having sex?
Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.
4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit
Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.5 For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.6
Physical exam
Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.
Sexual health counseling
Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.9 In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.
Email her at [email protected].
References
1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, in Center of Excellence for Transgender Health, Department of Family and Community Medicine, 2nd ed. (San Francisco: University of California, 2016).
2. Pediatrics. 2008. doi: 10.1542/peds.2008-0694.
3. J Adol Health. 2004;35:160-7.
4. An Overview of Minors’ Consent Law: State Laws and Policies. 2017, by the Guttmacher Institute.
5. Eur J Endocrinol. 2011 Aug;165(2):331-7.
6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
7. Sex Roles. 2013 Jun 1;68(11-12):675-89.
8. J Midwifery Womens Health. 2008 Jul-Aug;53(4):331-7.
9. “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,” 2nd ed. (Philadelphia: American College of Physicians Press, 2008).
Confronting hate and violence against the LGBT community
It may be unusual for an LGBT health columnist to mention the horrendous events that occurred in Charlottesville, Va., in August 2017. It clearly was a demonstration of hate and violence against racial and ethnic minorities. Unfortunately, the LGBT community – especially LGBT communities of color – are often a target of that kind of hate and violence. This has a detrimental effect on the health of the LGBT community, and I believe that health care providers have a responsibility to address this hate and violence to promote the well-being of this marginalized community.
It cannot be overstated that LGBT individuals frequently experience anti-gay and anti-trans violence. According to the 2015 Federal Bureau of Investigation Hate Crime Statistics, about a fifth of hate crimes reported were based on sexual orientation or gender identity.1 In addition, LGBT youth are eight times as likely to experience bullying at school because of their sexual orientation or gender identity.2 Furthermore, on many surveys on anti-LGBT violence, people of color comprise more than half of the victims.3 There is a strong association between exposure to this violence and the health outcomes of LGBT youth. A study by Russell et al. showed that LGBT youth who were victims of physical violence at school are more likely to be depressed and suicidal and more likely to be diagnosed with an STD,4 and another study showed that LGBT youth who experienced anti-LGBT violence are more likely to engage in substance use.5 The health outcomes from anti-LGBT violence are not limited to the adolescent period – adolescents who experienced this kind of violence are more likely to report higher levels of depression as adults.6 Although researchers still are trying to determine the exact mechanism for these relationships, the most cited (and sensible) explanation is that exposure to anti-LGBT stigma, discrimination, and violence leads to a toxic environment, which in turn increases the risk for mental health problems and maladaptive coping mechanisms (such as substance use) as a response to such an environment.7
What can we do to stand up to the hate and violence against marginalized groups, such as the LGBT community? First, make your office a safe space. With the recent brazen display of hate and violence going around, members the LGBT community are desperate to feel protected. A good place to start is a guide by Advocates for Youth. Second, educate yourself and others. The title physician means “teacher,” and I feel it is your responsibility to teach your peers, colleagues, and the public about how anti-LGBT violence affects the health of LGBT individuals. To be an effective teacher, you need to be up to date on the research on how hatred and intolerance affects the health of the LGBT community. A good place to start is the Human Rights Campaign, which has accurate statistics on anti-LGBT violence and resources to address this problem. Finally, be an advocate. You don’t need to be in the streets with picket signs, nor do you necessarily need to lead the charge against anti-LGBT hate and violence – others will be at the front lines. What you can do is to call for your local, state, and federal government to institute policies that address anti-LGBT violence. Many medical organizations have resources that help health care providers engage with policy makers (check out the American Academy of Pediatrics advocacy page for these resources). Many of our elected officials take our professional opinions seriously.
Anti-gay and anti-trans violence is all too common in the LGBT community, especially violence against LGBT people of color, and this violence can adversely affect their health. Health care providers have a responsibility and the influence to confront these nexuses of hate and intolerance. You don’t need to do something heroic to accomplish this. You are members of a privileged and respected group of professionals, so small actions can coalesce into something that has a large impact on the health and well-being of the communities you serve.
Resources
• Advocates for Youth. Creating Safe Space for GLBTQ Youth: A Toolkit
• Human Rights Campaign. www.hrc.org/resources/
• American Academy of Pediatrics advocacy page: www.aap.org/en-us/advocacy-and-policy/
References
1. U.S. Department of Justice Federal Bureau of Investigation. Uniform Crime Report Hate Crime Statistics, 2015.
2. J Interpers Violence. 2017. doi: 10.1177/0886260517718830.
3. National Coalition of Anti-Violence Programs (NCAVP). Lesbian, Gay, Bisexual, Transgender, Queer and HIV-Affected Hate Violence in 2016.
4. J Sch Health. 2011 May;81(5):223-30.
5. Prev Sci. 2015 Jul;16(5):734-43.
6. Dev Psychol. 2010 Nov;46(6):1580-9.
7. Psychol Bull. 2003 Sep;129(5):674-97.
8. Gallup. Americans Rate Healthcare Providers High on Honesty, Ethics. 2016.
9. The Hippocratic Oath Today. 2001 or Do. No. Harm.
It may be unusual for an LGBT health columnist to mention the horrendous events that occurred in Charlottesville, Va., in August 2017. It clearly was a demonstration of hate and violence against racial and ethnic minorities. Unfortunately, the LGBT community – especially LGBT communities of color – are often a target of that kind of hate and violence. This has a detrimental effect on the health of the LGBT community, and I believe that health care providers have a responsibility to address this hate and violence to promote the well-being of this marginalized community.
It cannot be overstated that LGBT individuals frequently experience anti-gay and anti-trans violence. According to the 2015 Federal Bureau of Investigation Hate Crime Statistics, about a fifth of hate crimes reported were based on sexual orientation or gender identity.1 In addition, LGBT youth are eight times as likely to experience bullying at school because of their sexual orientation or gender identity.2 Furthermore, on many surveys on anti-LGBT violence, people of color comprise more than half of the victims.3 There is a strong association between exposure to this violence and the health outcomes of LGBT youth. A study by Russell et al. showed that LGBT youth who were victims of physical violence at school are more likely to be depressed and suicidal and more likely to be diagnosed with an STD,4 and another study showed that LGBT youth who experienced anti-LGBT violence are more likely to engage in substance use.5 The health outcomes from anti-LGBT violence are not limited to the adolescent period – adolescents who experienced this kind of violence are more likely to report higher levels of depression as adults.6 Although researchers still are trying to determine the exact mechanism for these relationships, the most cited (and sensible) explanation is that exposure to anti-LGBT stigma, discrimination, and violence leads to a toxic environment, which in turn increases the risk for mental health problems and maladaptive coping mechanisms (such as substance use) as a response to such an environment.7
What can we do to stand up to the hate and violence against marginalized groups, such as the LGBT community? First, make your office a safe space. With the recent brazen display of hate and violence going around, members the LGBT community are desperate to feel protected. A good place to start is a guide by Advocates for Youth. Second, educate yourself and others. The title physician means “teacher,” and I feel it is your responsibility to teach your peers, colleagues, and the public about how anti-LGBT violence affects the health of LGBT individuals. To be an effective teacher, you need to be up to date on the research on how hatred and intolerance affects the health of the LGBT community. A good place to start is the Human Rights Campaign, which has accurate statistics on anti-LGBT violence and resources to address this problem. Finally, be an advocate. You don’t need to be in the streets with picket signs, nor do you necessarily need to lead the charge against anti-LGBT hate and violence – others will be at the front lines. What you can do is to call for your local, state, and federal government to institute policies that address anti-LGBT violence. Many medical organizations have resources that help health care providers engage with policy makers (check out the American Academy of Pediatrics advocacy page for these resources). Many of our elected officials take our professional opinions seriously.
Anti-gay and anti-trans violence is all too common in the LGBT community, especially violence against LGBT people of color, and this violence can adversely affect their health. Health care providers have a responsibility and the influence to confront these nexuses of hate and intolerance. You don’t need to do something heroic to accomplish this. You are members of a privileged and respected group of professionals, so small actions can coalesce into something that has a large impact on the health and well-being of the communities you serve.
Resources
• Advocates for Youth. Creating Safe Space for GLBTQ Youth: A Toolkit
• Human Rights Campaign. www.hrc.org/resources/
• American Academy of Pediatrics advocacy page: www.aap.org/en-us/advocacy-and-policy/
References
1. U.S. Department of Justice Federal Bureau of Investigation. Uniform Crime Report Hate Crime Statistics, 2015.
2. J Interpers Violence. 2017. doi: 10.1177/0886260517718830.
3. National Coalition of Anti-Violence Programs (NCAVP). Lesbian, Gay, Bisexual, Transgender, Queer and HIV-Affected Hate Violence in 2016.
4. J Sch Health. 2011 May;81(5):223-30.
5. Prev Sci. 2015 Jul;16(5):734-43.
6. Dev Psychol. 2010 Nov;46(6):1580-9.
7. Psychol Bull. 2003 Sep;129(5):674-97.
8. Gallup. Americans Rate Healthcare Providers High on Honesty, Ethics. 2016.
9. The Hippocratic Oath Today. 2001 or Do. No. Harm.
It may be unusual for an LGBT health columnist to mention the horrendous events that occurred in Charlottesville, Va., in August 2017. It clearly was a demonstration of hate and violence against racial and ethnic minorities. Unfortunately, the LGBT community – especially LGBT communities of color – are often a target of that kind of hate and violence. This has a detrimental effect on the health of the LGBT community, and I believe that health care providers have a responsibility to address this hate and violence to promote the well-being of this marginalized community.
It cannot be overstated that LGBT individuals frequently experience anti-gay and anti-trans violence. According to the 2015 Federal Bureau of Investigation Hate Crime Statistics, about a fifth of hate crimes reported were based on sexual orientation or gender identity.1 In addition, LGBT youth are eight times as likely to experience bullying at school because of their sexual orientation or gender identity.2 Furthermore, on many surveys on anti-LGBT violence, people of color comprise more than half of the victims.3 There is a strong association between exposure to this violence and the health outcomes of LGBT youth. A study by Russell et al. showed that LGBT youth who were victims of physical violence at school are more likely to be depressed and suicidal and more likely to be diagnosed with an STD,4 and another study showed that LGBT youth who experienced anti-LGBT violence are more likely to engage in substance use.5 The health outcomes from anti-LGBT violence are not limited to the adolescent period – adolescents who experienced this kind of violence are more likely to report higher levels of depression as adults.6 Although researchers still are trying to determine the exact mechanism for these relationships, the most cited (and sensible) explanation is that exposure to anti-LGBT stigma, discrimination, and violence leads to a toxic environment, which in turn increases the risk for mental health problems and maladaptive coping mechanisms (such as substance use) as a response to such an environment.7
What can we do to stand up to the hate and violence against marginalized groups, such as the LGBT community? First, make your office a safe space. With the recent brazen display of hate and violence going around, members the LGBT community are desperate to feel protected. A good place to start is a guide by Advocates for Youth. Second, educate yourself and others. The title physician means “teacher,” and I feel it is your responsibility to teach your peers, colleagues, and the public about how anti-LGBT violence affects the health of LGBT individuals. To be an effective teacher, you need to be up to date on the research on how hatred and intolerance affects the health of the LGBT community. A good place to start is the Human Rights Campaign, which has accurate statistics on anti-LGBT violence and resources to address this problem. Finally, be an advocate. You don’t need to be in the streets with picket signs, nor do you necessarily need to lead the charge against anti-LGBT hate and violence – others will be at the front lines. What you can do is to call for your local, state, and federal government to institute policies that address anti-LGBT violence. Many medical organizations have resources that help health care providers engage with policy makers (check out the American Academy of Pediatrics advocacy page for these resources). Many of our elected officials take our professional opinions seriously.
Anti-gay and anti-trans violence is all too common in the LGBT community, especially violence against LGBT people of color, and this violence can adversely affect their health. Health care providers have a responsibility and the influence to confront these nexuses of hate and intolerance. You don’t need to do something heroic to accomplish this. You are members of a privileged and respected group of professionals, so small actions can coalesce into something that has a large impact on the health and well-being of the communities you serve.
Resources
• Advocates for Youth. Creating Safe Space for GLBTQ Youth: A Toolkit
• Human Rights Campaign. www.hrc.org/resources/
• American Academy of Pediatrics advocacy page: www.aap.org/en-us/advocacy-and-policy/
References
1. U.S. Department of Justice Federal Bureau of Investigation. Uniform Crime Report Hate Crime Statistics, 2015.
2. J Interpers Violence. 2017. doi: 10.1177/0886260517718830.
3. National Coalition of Anti-Violence Programs (NCAVP). Lesbian, Gay, Bisexual, Transgender, Queer and HIV-Affected Hate Violence in 2016.
4. J Sch Health. 2011 May;81(5):223-30.
5. Prev Sci. 2015 Jul;16(5):734-43.
6. Dev Psychol. 2010 Nov;46(6):1580-9.
7. Psychol Bull. 2003 Sep;129(5):674-97.
8. Gallup. Americans Rate Healthcare Providers High on Honesty, Ethics. 2016.
9. The Hippocratic Oath Today. 2001 or Do. No. Harm.
Religion and LGBTQ identities
JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.
Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.1 For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.
- Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
- LGBT people exist in almost every faith group across the country.
- Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
- Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
- While every religion has different teachings, almost all religions advocate love and compassion.
- Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
- Remember this is your journey. You get to decide the path and the pace.
- Recognize that this may involve working for change within your community or it may mean leaving it.
- Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at [email protected].
Spirituality resources
- LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
- Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
- LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
- HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith
References
1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).
2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)
3. Pediatrics. 2013 Jul;132(1):198-203.
4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)
5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.
JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.
Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.1 For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.
- Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
- LGBT people exist in almost every faith group across the country.
- Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
- Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
- While every religion has different teachings, almost all religions advocate love and compassion.
- Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
- Remember this is your journey. You get to decide the path and the pace.
- Recognize that this may involve working for change within your community or it may mean leaving it.
- Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at [email protected].
Spirituality resources
- LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
- Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
- LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
- HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith
References
1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).
2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)
3. Pediatrics. 2013 Jul;132(1):198-203.
4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)
5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.
JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.
Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.1 For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.
- Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
- LGBT people exist in almost every faith group across the country.
- Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
- Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
- While every religion has different teachings, almost all religions advocate love and compassion.
- Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
- Remember this is your journey. You get to decide the path and the pace.
- Recognize that this may involve working for change within your community or it may mean leaving it.
- Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at [email protected].
Spirituality resources
- LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
- Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
- LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
- HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith
References
1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).
2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)
3. Pediatrics. 2013 Jul;132(1):198-203.
4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)
5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.
Obtaining coverage for transgender and gender-expansive youth
Transgender and gender-expansive youth face many barriers to health care. (Gender-expansive youth are defined as “youth who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience.”) Although some of these youth may be fortunate to have a supportive family and access to health care providers proficient in transgender health care, they still face difficulties in having their insurance cover transgender-related services. This is not an impossible task, but it is a constant struggle for many clinicians.
In this column, I will provide some tips and strategies to help clinicians get insurance companies to cover these critical services. However, keep in mind that there is no one-size-fits-all approach to obtaining insurance coverage. In addition, growing uncertainty over the repeal of the Affordable Care Act (ACA) – which was critical in lifting many of the barriers to insurance coverage for transgender individuals – will make this task challenging.
Health insurance is extraordinarily complex. There are multiple private and public plans that vary in the services they cover. This variation is state dependent. And even within states, there is additional variability. Most health insurance plans are purchased by employers, and employers have a choice of what can be covered in their health plans. So even though an insurance company may state that it covers transgender-related services, the patient’s employer may pay for a plan that doesn’t cover such services. The only way to be sure whether a patient’s insurance will cover transgender-related services or not is to contact the insurance provider directly, but with extremely busy schedules and heavy patient loads, this is easier said than done. It would be helpful to have a social worker perform this task, but even having a social worker can be a luxury for some clinics.
The ACA made it easier for transgender individuals to obtain insurance coverage. Three years ago, the U.S. Department of Health and Human Services stated that Medicare’s longstanding exclusion of “transsexual surgical procedures” was no longer valid.1 Although it did not universally ban transgender exclusion policies, it did allow individual states to do so. Thirteen states have explicit policies that ban exclusions of transgender-related services in both private insurance and in Medicaid, and an additional five states have some policies that discourage such practices.2 This allowed some insurance providers and state Medicaid plans to offer coverage of transgender-related services.
Another challenge in obtaining insurance coverage for transgender and gender-expansive youth is claims denial for sex-specific procedures. For example, if a transwoman is designated as “male” in the electronic medical record and requires a breast ultrasound, the insurance company may automatically reject this claim because this procedure is covered for bodies designated as “female.” If the patient’s insurance plan covers transgender-related services, the clinic can notify the insurance company that the patient is transgender; if the patient’s plan does not, then the clinic will need to appeal to the insurance provider. Alternatively, for clinics associated with federally-funded institutions (e.g., most hospitals), the clinician can use Condition Code 45 in the billing to override the sex mismatch, although not all hospitals have implemented this code.3
1. Patient’s identifying information. Usually the patient’s name and date of birth is sufficient. Clinicians should use the patient’s preferred name in the letter, but provide the insurance or legal name of the patient so that the insurance provider can locate the patient’s records.
2. Result of a psychosocial evaluation and diagnosis (if any). Many insurance providers are looking specifically for the gender dysphoria diagnosis.
3. The duration of the referring health professional’s relationship with the patient, which includes the type of evaluation and therapy or counseling (e.g., cognitive behavior therapy or gender coaching).
4. An explanation that the criteria (usually from the World Professional Association for Transgender Health standard of care4 or the Endocrine Society Guidelines titled Endocrine Treatment of Transsexual Persons5) for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy.
5. A statement that informed consent has been obtained from the patient (or parental permission if the patient is younger than 18 years).
6. A statement that the referring health professional is available for coordination of care.
If the clinician fails to convince the insurance provider of the necessity of covering transgender-related services, the patient still can pay out of pocket. Some hormones can be affordable to certain patients. In the state of Pennsylvania, for example, a 10-mL vial of testosterone can cost anywhere from $60 to $80, and may generally last anywhere from 10 weeks to a year, depending on dosage. Nevertheless, these costs still may be prohibitive for many transgender youth. Many are chronically unemployed or underemployed, or struggle with homelessness.6 Some transgender youth have to the face the excruciatingly difficult choice between having something to eat for the day or living another day with gender dysphoria.
Clinicians should work very hard to make sure that their transgender and gender-expansive patients obtain the care they need. The above strategies may help navigate the complex insurance system. However, insurance policies vary by state, and anti-trans discrimination creates additional barriers to health care. Therefore, clinicians who take care of transgender youth also should advocate for policies that protect these patients from discrimination, and they should advocate for policies that expand medical coverage for this vulnerable population.
Resources
• The Human Rights Campaign keeps a list of insurance plans that cover transgender-related services, but this list is far from comprehensive.
• Healthcare.gov provides some guidance on how to obtain coverage and navigate the insurance system for transgender individuals.
• UCSF Center of Excellence for Transgender Health provides some excellent resources and guidance on obtaining insurance coverage for transgender individuals.
References
1. LGBT Health 2014;1(4):256-8.
2. Map: State Health Insurance Rules: National Center for Transgender Equality, 2016 [Available from: www.transequality.org/issues/resources/map-state-health-insurance-rules].
3. Health insurance coverage issues for transgender people in the United States: University of California, San Fransisco Center of Excellence for Transgender Health, 2017 [Available from: http://transhealth.ucsf.edu/trans?page=guidelines-insurance].
4. International Journal of Transgenderism 2012;13(4):165-232.
5. J Clin Endocrinol Metab 2009;94(9):3132-54.
6. 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.
Transgender and gender-expansive youth face many barriers to health care. (Gender-expansive youth are defined as “youth who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience.”) Although some of these youth may be fortunate to have a supportive family and access to health care providers proficient in transgender health care, they still face difficulties in having their insurance cover transgender-related services. This is not an impossible task, but it is a constant struggle for many clinicians.
In this column, I will provide some tips and strategies to help clinicians get insurance companies to cover these critical services. However, keep in mind that there is no one-size-fits-all approach to obtaining insurance coverage. In addition, growing uncertainty over the repeal of the Affordable Care Act (ACA) – which was critical in lifting many of the barriers to insurance coverage for transgender individuals – will make this task challenging.
Health insurance is extraordinarily complex. There are multiple private and public plans that vary in the services they cover. This variation is state dependent. And even within states, there is additional variability. Most health insurance plans are purchased by employers, and employers have a choice of what can be covered in their health plans. So even though an insurance company may state that it covers transgender-related services, the patient’s employer may pay for a plan that doesn’t cover such services. The only way to be sure whether a patient’s insurance will cover transgender-related services or not is to contact the insurance provider directly, but with extremely busy schedules and heavy patient loads, this is easier said than done. It would be helpful to have a social worker perform this task, but even having a social worker can be a luxury for some clinics.
The ACA made it easier for transgender individuals to obtain insurance coverage. Three years ago, the U.S. Department of Health and Human Services stated that Medicare’s longstanding exclusion of “transsexual surgical procedures” was no longer valid.1 Although it did not universally ban transgender exclusion policies, it did allow individual states to do so. Thirteen states have explicit policies that ban exclusions of transgender-related services in both private insurance and in Medicaid, and an additional five states have some policies that discourage such practices.2 This allowed some insurance providers and state Medicaid plans to offer coverage of transgender-related services.
Another challenge in obtaining insurance coverage for transgender and gender-expansive youth is claims denial for sex-specific procedures. For example, if a transwoman is designated as “male” in the electronic medical record and requires a breast ultrasound, the insurance company may automatically reject this claim because this procedure is covered for bodies designated as “female.” If the patient’s insurance plan covers transgender-related services, the clinic can notify the insurance company that the patient is transgender; if the patient’s plan does not, then the clinic will need to appeal to the insurance provider. Alternatively, for clinics associated with federally-funded institutions (e.g., most hospitals), the clinician can use Condition Code 45 in the billing to override the sex mismatch, although not all hospitals have implemented this code.3
1. Patient’s identifying information. Usually the patient’s name and date of birth is sufficient. Clinicians should use the patient’s preferred name in the letter, but provide the insurance or legal name of the patient so that the insurance provider can locate the patient’s records.
2. Result of a psychosocial evaluation and diagnosis (if any). Many insurance providers are looking specifically for the gender dysphoria diagnosis.
3. The duration of the referring health professional’s relationship with the patient, which includes the type of evaluation and therapy or counseling (e.g., cognitive behavior therapy or gender coaching).
4. An explanation that the criteria (usually from the World Professional Association for Transgender Health standard of care4 or the Endocrine Society Guidelines titled Endocrine Treatment of Transsexual Persons5) for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy.
5. A statement that informed consent has been obtained from the patient (or parental permission if the patient is younger than 18 years).
6. A statement that the referring health professional is available for coordination of care.
If the clinician fails to convince the insurance provider of the necessity of covering transgender-related services, the patient still can pay out of pocket. Some hormones can be affordable to certain patients. In the state of Pennsylvania, for example, a 10-mL vial of testosterone can cost anywhere from $60 to $80, and may generally last anywhere from 10 weeks to a year, depending on dosage. Nevertheless, these costs still may be prohibitive for many transgender youth. Many are chronically unemployed or underemployed, or struggle with homelessness.6 Some transgender youth have to the face the excruciatingly difficult choice between having something to eat for the day or living another day with gender dysphoria.
Clinicians should work very hard to make sure that their transgender and gender-expansive patients obtain the care they need. The above strategies may help navigate the complex insurance system. However, insurance policies vary by state, and anti-trans discrimination creates additional barriers to health care. Therefore, clinicians who take care of transgender youth also should advocate for policies that protect these patients from discrimination, and they should advocate for policies that expand medical coverage for this vulnerable population.
Resources
• The Human Rights Campaign keeps a list of insurance plans that cover transgender-related services, but this list is far from comprehensive.
• Healthcare.gov provides some guidance on how to obtain coverage and navigate the insurance system for transgender individuals.
• UCSF Center of Excellence for Transgender Health provides some excellent resources and guidance on obtaining insurance coverage for transgender individuals.
References
1. LGBT Health 2014;1(4):256-8.
2. Map: State Health Insurance Rules: National Center for Transgender Equality, 2016 [Available from: www.transequality.org/issues/resources/map-state-health-insurance-rules].
3. Health insurance coverage issues for transgender people in the United States: University of California, San Fransisco Center of Excellence for Transgender Health, 2017 [Available from: http://transhealth.ucsf.edu/trans?page=guidelines-insurance].
4. International Journal of Transgenderism 2012;13(4):165-232.
5. J Clin Endocrinol Metab 2009;94(9):3132-54.
6. 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.
Transgender and gender-expansive youth face many barriers to health care. (Gender-expansive youth are defined as “youth who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience.”) Although some of these youth may be fortunate to have a supportive family and access to health care providers proficient in transgender health care, they still face difficulties in having their insurance cover transgender-related services. This is not an impossible task, but it is a constant struggle for many clinicians.
In this column, I will provide some tips and strategies to help clinicians get insurance companies to cover these critical services. However, keep in mind that there is no one-size-fits-all approach to obtaining insurance coverage. In addition, growing uncertainty over the repeal of the Affordable Care Act (ACA) – which was critical in lifting many of the barriers to insurance coverage for transgender individuals – will make this task challenging.
Health insurance is extraordinarily complex. There are multiple private and public plans that vary in the services they cover. This variation is state dependent. And even within states, there is additional variability. Most health insurance plans are purchased by employers, and employers have a choice of what can be covered in their health plans. So even though an insurance company may state that it covers transgender-related services, the patient’s employer may pay for a plan that doesn’t cover such services. The only way to be sure whether a patient’s insurance will cover transgender-related services or not is to contact the insurance provider directly, but with extremely busy schedules and heavy patient loads, this is easier said than done. It would be helpful to have a social worker perform this task, but even having a social worker can be a luxury for some clinics.
The ACA made it easier for transgender individuals to obtain insurance coverage. Three years ago, the U.S. Department of Health and Human Services stated that Medicare’s longstanding exclusion of “transsexual surgical procedures” was no longer valid.1 Although it did not universally ban transgender exclusion policies, it did allow individual states to do so. Thirteen states have explicit policies that ban exclusions of transgender-related services in both private insurance and in Medicaid, and an additional five states have some policies that discourage such practices.2 This allowed some insurance providers and state Medicaid plans to offer coverage of transgender-related services.
Another challenge in obtaining insurance coverage for transgender and gender-expansive youth is claims denial for sex-specific procedures. For example, if a transwoman is designated as “male” in the electronic medical record and requires a breast ultrasound, the insurance company may automatically reject this claim because this procedure is covered for bodies designated as “female.” If the patient’s insurance plan covers transgender-related services, the clinic can notify the insurance company that the patient is transgender; if the patient’s plan does not, then the clinic will need to appeal to the insurance provider. Alternatively, for clinics associated with federally-funded institutions (e.g., most hospitals), the clinician can use Condition Code 45 in the billing to override the sex mismatch, although not all hospitals have implemented this code.3
1. Patient’s identifying information. Usually the patient’s name and date of birth is sufficient. Clinicians should use the patient’s preferred name in the letter, but provide the insurance or legal name of the patient so that the insurance provider can locate the patient’s records.
2. Result of a psychosocial evaluation and diagnosis (if any). Many insurance providers are looking specifically for the gender dysphoria diagnosis.
3. The duration of the referring health professional’s relationship with the patient, which includes the type of evaluation and therapy or counseling (e.g., cognitive behavior therapy or gender coaching).
4. An explanation that the criteria (usually from the World Professional Association for Transgender Health standard of care4 or the Endocrine Society Guidelines titled Endocrine Treatment of Transsexual Persons5) for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy.
5. A statement that informed consent has been obtained from the patient (or parental permission if the patient is younger than 18 years).
6. A statement that the referring health professional is available for coordination of care.
If the clinician fails to convince the insurance provider of the necessity of covering transgender-related services, the patient still can pay out of pocket. Some hormones can be affordable to certain patients. In the state of Pennsylvania, for example, a 10-mL vial of testosterone can cost anywhere from $60 to $80, and may generally last anywhere from 10 weeks to a year, depending on dosage. Nevertheless, these costs still may be prohibitive for many transgender youth. Many are chronically unemployed or underemployed, or struggle with homelessness.6 Some transgender youth have to the face the excruciatingly difficult choice between having something to eat for the day or living another day with gender dysphoria.
Clinicians should work very hard to make sure that their transgender and gender-expansive patients obtain the care they need. The above strategies may help navigate the complex insurance system. However, insurance policies vary by state, and anti-trans discrimination creates additional barriers to health care. Therefore, clinicians who take care of transgender youth also should advocate for policies that protect these patients from discrimination, and they should advocate for policies that expand medical coverage for this vulnerable population.
Resources
• The Human Rights Campaign keeps a list of insurance plans that cover transgender-related services, but this list is far from comprehensive.
• Healthcare.gov provides some guidance on how to obtain coverage and navigate the insurance system for transgender individuals.
• UCSF Center of Excellence for Transgender Health provides some excellent resources and guidance on obtaining insurance coverage for transgender individuals.
References
1. LGBT Health 2014;1(4):256-8.
2. Map: State Health Insurance Rules: National Center for Transgender Equality, 2016 [Available from: www.transequality.org/issues/resources/map-state-health-insurance-rules].
3. Health insurance coverage issues for transgender people in the United States: University of California, San Fransisco Center of Excellence for Transgender Health, 2017 [Available from: http://transhealth.ucsf.edu/trans?page=guidelines-insurance].
4. International Journal of Transgenderism 2012;13(4):165-232.
5. J Clin Endocrinol Metab 2009;94(9):3132-54.
6. 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.
Adolescent sexuality and disclosure
Adolescence is a time of rapid growth and development both physically and emotionally. Some of the major tasks of adolescent development include developing a stable identity (this includes sexual and gender identity) and establishing independence from parents. This separation process from parents is often buffered by peer relationships. By the end of adolescence, those who are healthy and mature in their sexuality are able to:1,2,3
• Identify and live according to their own values and take responsibility for their behavior.
• Practice effective decision-making, and develop critical-thinking skills.
• Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.
• Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.
• Interact with all genders in respectful and appropriate ways.
• Affirm their own gender identity and sexual orientation, and respect the gender identities and sexual orientations of others.
• Appreciate their body and enjoy their sexuality throughout life, expressing sexuality in ways that are congruent with their values.
• Express love and intimacy in appropriate ways.
• Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.
• Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.
Anywhere from 5% to 10% of teens identify as lesbian, gay, or bisexual (LGB).4 For these teens, the development of a sexual identity can add additional challenges to the development process, particularly if youth do not feel supported by family, peers, and their communities. Previous columns have addressed the role family acceptance can play in promoting the healthy development of sexual minority youth. Likewise, peer relationships also can play an important role in an adolescent’s development and health.
Some factors that can promote resilience and counteract stigma that LGB youth may face include:5
• Acceptance.
• Competence.
• Higher levels of self-esteem and psychological well-being.
• Strong sense of self and self-acceptance.
• Strong ethnic identification.
• Strong connections to family and school.
• Caring adult role models outside the family.
• Community involvement.
For some youth who may not be able receive acceptance from their families, peers and trusted adults may fill in this role and serve as a “chosen family.” A chosen family is commonly understood to mean a group of people who deliberately chose one another to play significant roles in each other’s lives even though they are not biologically or legally related. These relationships may be in addition to or in place of traditional family relationships. These connections can increase a youth’s sense of acceptance and connectedness and help promote resiliency.
Adolescents often may struggle on the decision of when to “come out” or disclose their sexual orientation to friends and family, and may ask their health care providers for advice. The number one consideration when making a decision about disclosure is safety. Unfortunately, some family members and peers may not react in a supportive manner to a youth’s disclosure, and disclosure may result in being kicked out, financial coercion, bullying, physical violence, or alienation. In these cases, youth may choose to delay disclosure until they are in a more supportive environment, and health care providers can play an important role in validating and affirming patients’ identities and maintaining confidentiality as appropriate. They also should plan for how they might deal with a negative or rejecting response. Some tips are included below.5
When
• You are ready.
• You are comfortable with your identity.
• You want to share information with people you trust and are close to.
• You have a plan for support if you are not accepted (particularly when coming out to family).
Who
• Someone you know well and expect to be supportive.
• Someone you trust, feel safe with, and who can keep information confidential if needed (may need to explore school’s privacy and confidentiality policies if disclosing to a teacher or school personnel).
• Be clear about who else information may be shared with and who NOT to share with.
How
• Be sure you are prepared. You may want to talk to other sexual minority youth or adults who have come out, attend LGBTQ groups/forums, or seek out Internet resources to learn about others’ coming out experiences. These sources may serve as a support for you should you experience any negative or rejecting responses.
• Make sure you have support resources in place prior to coming out.
• Coming out by letter allows you time to carefully word what you want to say, and allows the other person time and privacy to consider their response.
• If coming out in person, try to choose a quiet private space, and try to choose a time when everyone is relaxed and well-rested.
• If concerned about your safety, make sure other people are immediately accessible if needed.
• Plan what you are going to say, how you might end the conversation, and how you may want to talk about it later.
• Listen actively to what the other person has to say.
• Avoid any alcohol or drugs, as these may affect your mental and emotional state and responses.
• Avoid coming out because of pressure from others or because you are angry.
Youth should be reminded that people’s responses may not always be predictable. It is important to note that for many individuals, coming out may be a lifelong process and occur in stages, beginning with close friends or family members and progressing from there. In the age of social media, youth should be reminded that disclosures through social media may be widely accessible, are easily shared, and may be difficult to remove. For youth who do not have supportive peer groups, and may not be able to disclose their sexual identity, providing support resources can be helpful.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at [email protected].
Resources for sexual minority youth and peers/families
Gay-Straight Alliance Network: gsanetwork.org
Gay Lesbian Straight Education Network: Information for Students: glsen.org/students
Sexuality Information and Education Council of the United States: www.siecus.org
The Trevor Project: Help and Suicide Prevention: www.thetrevorproject.org
It Gets Better Project: http://www.itgetsbetter.org/
Family and Ally Organization: PFLAG: https://www.pflag.org/
Advocates for Youth Parent Tips: http://www.advocatesforyouth.org/parents/173-parents
References
1. “Adolescent Sexuality,” by Michelle Forcier, MD, in Up to Date. Updated March 2017.
2. Pediatrics. 2016 Aug;138(2). pii: e20161348.
3. The Guidelines for Comprehensive Sexuality Education: Grades K-12 (Washington, D.C.: Sexuality Information and Education Council of the United States, 2004).
4. MMWR Surveillance Summaries, 2016, Aug 12;65(9):1-202.
5. “Sexual minority youth: Epidemiology and health concerns,” by Michelle Forcier, MD, and Johanna Olson-Kennedy, MD, in Up to Date.
Adolescence is a time of rapid growth and development both physically and emotionally. Some of the major tasks of adolescent development include developing a stable identity (this includes sexual and gender identity) and establishing independence from parents. This separation process from parents is often buffered by peer relationships. By the end of adolescence, those who are healthy and mature in their sexuality are able to:1,2,3
• Identify and live according to their own values and take responsibility for their behavior.
• Practice effective decision-making, and develop critical-thinking skills.
• Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.
• Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.
• Interact with all genders in respectful and appropriate ways.
• Affirm their own gender identity and sexual orientation, and respect the gender identities and sexual orientations of others.
• Appreciate their body and enjoy their sexuality throughout life, expressing sexuality in ways that are congruent with their values.
• Express love and intimacy in appropriate ways.
• Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.
• Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.
Anywhere from 5% to 10% of teens identify as lesbian, gay, or bisexual (LGB).4 For these teens, the development of a sexual identity can add additional challenges to the development process, particularly if youth do not feel supported by family, peers, and their communities. Previous columns have addressed the role family acceptance can play in promoting the healthy development of sexual minority youth. Likewise, peer relationships also can play an important role in an adolescent’s development and health.
Some factors that can promote resilience and counteract stigma that LGB youth may face include:5
• Acceptance.
• Competence.
• Higher levels of self-esteem and psychological well-being.
• Strong sense of self and self-acceptance.
• Strong ethnic identification.
• Strong connections to family and school.
• Caring adult role models outside the family.
• Community involvement.
For some youth who may not be able receive acceptance from their families, peers and trusted adults may fill in this role and serve as a “chosen family.” A chosen family is commonly understood to mean a group of people who deliberately chose one another to play significant roles in each other’s lives even though they are not biologically or legally related. These relationships may be in addition to or in place of traditional family relationships. These connections can increase a youth’s sense of acceptance and connectedness and help promote resiliency.
Adolescents often may struggle on the decision of when to “come out” or disclose their sexual orientation to friends and family, and may ask their health care providers for advice. The number one consideration when making a decision about disclosure is safety. Unfortunately, some family members and peers may not react in a supportive manner to a youth’s disclosure, and disclosure may result in being kicked out, financial coercion, bullying, physical violence, or alienation. In these cases, youth may choose to delay disclosure until they are in a more supportive environment, and health care providers can play an important role in validating and affirming patients’ identities and maintaining confidentiality as appropriate. They also should plan for how they might deal with a negative or rejecting response. Some tips are included below.5
When
• You are ready.
• You are comfortable with your identity.
• You want to share information with people you trust and are close to.
• You have a plan for support if you are not accepted (particularly when coming out to family).
Who
• Someone you know well and expect to be supportive.
• Someone you trust, feel safe with, and who can keep information confidential if needed (may need to explore school’s privacy and confidentiality policies if disclosing to a teacher or school personnel).
• Be clear about who else information may be shared with and who NOT to share with.
How
• Be sure you are prepared. You may want to talk to other sexual minority youth or adults who have come out, attend LGBTQ groups/forums, or seek out Internet resources to learn about others’ coming out experiences. These sources may serve as a support for you should you experience any negative or rejecting responses.
• Make sure you have support resources in place prior to coming out.
• Coming out by letter allows you time to carefully word what you want to say, and allows the other person time and privacy to consider their response.
• If coming out in person, try to choose a quiet private space, and try to choose a time when everyone is relaxed and well-rested.
• If concerned about your safety, make sure other people are immediately accessible if needed.
• Plan what you are going to say, how you might end the conversation, and how you may want to talk about it later.
• Listen actively to what the other person has to say.
• Avoid any alcohol or drugs, as these may affect your mental and emotional state and responses.
• Avoid coming out because of pressure from others or because you are angry.
Youth should be reminded that people’s responses may not always be predictable. It is important to note that for many individuals, coming out may be a lifelong process and occur in stages, beginning with close friends or family members and progressing from there. In the age of social media, youth should be reminded that disclosures through social media may be widely accessible, are easily shared, and may be difficult to remove. For youth who do not have supportive peer groups, and may not be able to disclose their sexual identity, providing support resources can be helpful.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at [email protected].
Resources for sexual minority youth and peers/families
Gay-Straight Alliance Network: gsanetwork.org
Gay Lesbian Straight Education Network: Information for Students: glsen.org/students
Sexuality Information and Education Council of the United States: www.siecus.org
The Trevor Project: Help and Suicide Prevention: www.thetrevorproject.org
It Gets Better Project: http://www.itgetsbetter.org/
Family and Ally Organization: PFLAG: https://www.pflag.org/
Advocates for Youth Parent Tips: http://www.advocatesforyouth.org/parents/173-parents
References
1. “Adolescent Sexuality,” by Michelle Forcier, MD, in Up to Date. Updated March 2017.
2. Pediatrics. 2016 Aug;138(2). pii: e20161348.
3. The Guidelines for Comprehensive Sexuality Education: Grades K-12 (Washington, D.C.: Sexuality Information and Education Council of the United States, 2004).
4. MMWR Surveillance Summaries, 2016, Aug 12;65(9):1-202.
5. “Sexual minority youth: Epidemiology and health concerns,” by Michelle Forcier, MD, and Johanna Olson-Kennedy, MD, in Up to Date.
Adolescence is a time of rapid growth and development both physically and emotionally. Some of the major tasks of adolescent development include developing a stable identity (this includes sexual and gender identity) and establishing independence from parents. This separation process from parents is often buffered by peer relationships. By the end of adolescence, those who are healthy and mature in their sexuality are able to:1,2,3
• Identify and live according to their own values and take responsibility for their behavior.
• Practice effective decision-making, and develop critical-thinking skills.
• Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.
• Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.
• Interact with all genders in respectful and appropriate ways.
• Affirm their own gender identity and sexual orientation, and respect the gender identities and sexual orientations of others.
• Appreciate their body and enjoy their sexuality throughout life, expressing sexuality in ways that are congruent with their values.
• Express love and intimacy in appropriate ways.
• Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.
• Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.
Anywhere from 5% to 10% of teens identify as lesbian, gay, or bisexual (LGB).4 For these teens, the development of a sexual identity can add additional challenges to the development process, particularly if youth do not feel supported by family, peers, and their communities. Previous columns have addressed the role family acceptance can play in promoting the healthy development of sexual minority youth. Likewise, peer relationships also can play an important role in an adolescent’s development and health.
Some factors that can promote resilience and counteract stigma that LGB youth may face include:5
• Acceptance.
• Competence.
• Higher levels of self-esteem and psychological well-being.
• Strong sense of self and self-acceptance.
• Strong ethnic identification.
• Strong connections to family and school.
• Caring adult role models outside the family.
• Community involvement.
For some youth who may not be able receive acceptance from their families, peers and trusted adults may fill in this role and serve as a “chosen family.” A chosen family is commonly understood to mean a group of people who deliberately chose one another to play significant roles in each other’s lives even though they are not biologically or legally related. These relationships may be in addition to or in place of traditional family relationships. These connections can increase a youth’s sense of acceptance and connectedness and help promote resiliency.
Adolescents often may struggle on the decision of when to “come out” or disclose their sexual orientation to friends and family, and may ask their health care providers for advice. The number one consideration when making a decision about disclosure is safety. Unfortunately, some family members and peers may not react in a supportive manner to a youth’s disclosure, and disclosure may result in being kicked out, financial coercion, bullying, physical violence, or alienation. In these cases, youth may choose to delay disclosure until they are in a more supportive environment, and health care providers can play an important role in validating and affirming patients’ identities and maintaining confidentiality as appropriate. They also should plan for how they might deal with a negative or rejecting response. Some tips are included below.5
When
• You are ready.
• You are comfortable with your identity.
• You want to share information with people you trust and are close to.
• You have a plan for support if you are not accepted (particularly when coming out to family).
Who
• Someone you know well and expect to be supportive.
• Someone you trust, feel safe with, and who can keep information confidential if needed (may need to explore school’s privacy and confidentiality policies if disclosing to a teacher or school personnel).
• Be clear about who else information may be shared with and who NOT to share with.
How
• Be sure you are prepared. You may want to talk to other sexual minority youth or adults who have come out, attend LGBTQ groups/forums, or seek out Internet resources to learn about others’ coming out experiences. These sources may serve as a support for you should you experience any negative or rejecting responses.
• Make sure you have support resources in place prior to coming out.
• Coming out by letter allows you time to carefully word what you want to say, and allows the other person time and privacy to consider their response.
• If coming out in person, try to choose a quiet private space, and try to choose a time when everyone is relaxed and well-rested.
• If concerned about your safety, make sure other people are immediately accessible if needed.
• Plan what you are going to say, how you might end the conversation, and how you may want to talk about it later.
• Listen actively to what the other person has to say.
• Avoid any alcohol or drugs, as these may affect your mental and emotional state and responses.
• Avoid coming out because of pressure from others or because you are angry.
Youth should be reminded that people’s responses may not always be predictable. It is important to note that for many individuals, coming out may be a lifelong process and occur in stages, beginning with close friends or family members and progressing from there. In the age of social media, youth should be reminded that disclosures through social media may be widely accessible, are easily shared, and may be difficult to remove. For youth who do not have supportive peer groups, and may not be able to disclose their sexual identity, providing support resources can be helpful.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at [email protected].
Resources for sexual minority youth and peers/families
Gay-Straight Alliance Network: gsanetwork.org
Gay Lesbian Straight Education Network: Information for Students: glsen.org/students
Sexuality Information and Education Council of the United States: www.siecus.org
The Trevor Project: Help and Suicide Prevention: www.thetrevorproject.org
It Gets Better Project: http://www.itgetsbetter.org/
Family and Ally Organization: PFLAG: https://www.pflag.org/
Advocates for Youth Parent Tips: http://www.advocatesforyouth.org/parents/173-parents
References
1. “Adolescent Sexuality,” by Michelle Forcier, MD, in Up to Date. Updated March 2017.
2. Pediatrics. 2016 Aug;138(2). pii: e20161348.
3. The Guidelines for Comprehensive Sexuality Education: Grades K-12 (Washington, D.C.: Sexuality Information and Education Council of the United States, 2004).
4. MMWR Surveillance Summaries, 2016, Aug 12;65(9):1-202.
5. “Sexual minority youth: Epidemiology and health concerns,” by Michelle Forcier, MD, and Johanna Olson-Kennedy, MD, in Up to Date.
Why state and school policies matter
Recently North Carolina proposed a bill (House Bill 780) that will ban same-sex marriage in the state, even though the U.S. Supreme Court ruled in 2015 that no states can ban same-sex marriage because doing so violates the 14th Amendment. Although many mainly will argue that H.B. 780 is unconstitutional, this bill also can be detrimental to the health of lesbian, gay, and bisexual (LGB) youth.
In March 2017, JAMA Pediatrics published a study on the association between same-sex marriage laws and the rates of suicide attempts.1 Using data from the Youth Risk Behavior Surveillance System, they analyzed the relationship between state policies that permitted same-sex marriage and self-report of suicide attempts within the last 12 months. Thirty percent of LGB youth (13% of the survey population) reported a suicide attempt in the past year prior to any state policies that permitted same-sex marriage, compared with about 9% of the general population. After states implemented pro–same-sex marriage policies, LGB youth suicide attempts dropped to about 26% – a 14% relative decline. This was not limited to LGB youth. The general youth suicide rates declined from 8.6% to 8% – a 7% relative decline. Although the change in suicide attempts was small, the authors determined that the likelihood it occurred by chance was very slim, and concluded that policies enabling same-sex marriage may be associated with an improvement in population health, especially for LGB youth.
This was not the first study examining the relationship between policies and the health of LGB youth. Mark Hatzenbuehler, PhD, of Columbia University, New York, and his associates have published multiple studies on this topic. Four years earlier, Hatzenbuehler et al. published a study on the relationship between antibullying policies and suicide among LGB youth. Using data from the Oregon Healthy Teen survey (2006-2008), he found that LGB youth who live in counties where there are fewer districts with antibullying policies are more than twice as likely to attempt suicide, compared with LGB youth who live in counties where more districts had antibullying policies. Furthermore, the type of antibullying policy mattered. If a district’s antibullying policy did not prohibit bullying based on sexual orientation, then it had no impact on the suicide attempt rates of LGB youth in that area.2 Similar results were found when the relationship between anti–homophobic bullying policies and LGB suicide attempts was examined in the larger Youth Risk Behavior Surveillance System.3
State and local policies also influence other health outcomes among LGB youth. Hatzenbuehler et al. did another study that examined community-level determinants of tobacco use among LGB youth. Again using the data from the Oregon Healthy Teen Survey, they found that LGB youth living in communities that were more supportive of LGB youth (i.e., communities with a high proportion of same-sex couples living in the area, a high proportion of gay-straight alliances at schools, and LGB-specific antibullying policies) were less likely to smoke cigarettes, compared with LGB youth living in communities that were less supportive.4 A similar study in Canada by Konishi et al. found that schools with gay-straight alliances and anti–homophobic bullying policies were less likely to have LGB youth engaging in risky alcohol or illicit drug use.5
Why do these policies matter? A common theme among these policies is that they can either cause or alleviate stress for LGB youth. States that restrict same-sex marriages or schools that do not have any gay-straight alliances may signal to LGB youth that they are not valued or welcomed, or at the very worse, are despised. This creates a hostile and stressful environment for LGB youth, which raises the risk for mental health problems, such as depression and anxiety, which in turn, raises the risk for substance use and suicide.6 Conversely, the presence of a gay-straight alliance at school or a state that allows same-sex marriage may indicate to LGB youth that they are welcomed, if not just tolerated, and may alleviate this risk. Furthermore, antibullying policies seem to reduce the stress associated with bullying among LGB youth because it may serve as a deterrent to bullying based on sexual orientation. Although passing pro-LGB policies will not solve all the health problems among LGB youth, these policies certainly have an impact.
There might be trepidation among some pediatricians about being vocal on a politically charged policy proposal such as H.B. 780. However, suicide and substance use are major concerns for all physicians – especially pediatricians. Policy makers considering passing laws that can affect their LGB constituents should read these studies to see what kind of influence these proposals can have on the health and well-being of LGB youth. Moreover, health care providers should use their expertise, influence, and standing in their community to support policies that encourage protection for LGB youth and oppose policies that can harm LGB youth. These leaders are responsible for ensuring the health of the people they serve.
Dr. Montano is clinical instructor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC.
References
1. JAMA Pediatr. 2017. doi: 10.1001/jamapediatrics.2016.4529.
2. J Adolesc Health. 2013:S21-6. doi: 10.1016/j.jadohealth.2012.08.010.
3. Am J Public Health. 2014. doi: 10.2105/AJPH.2013.301508.
4. Arch Pediatr Adolesc Med. 2011. doi: 10.1001/archpediatrics.2011.64.
5. Prev Med. 2013. doi: 10.1016/j.ypmed.2013.06.031.
6. Psychol Bull. 2003. doi: 10.1037/0033-2909.129.5.674.
Recently North Carolina proposed a bill (House Bill 780) that will ban same-sex marriage in the state, even though the U.S. Supreme Court ruled in 2015 that no states can ban same-sex marriage because doing so violates the 14th Amendment. Although many mainly will argue that H.B. 780 is unconstitutional, this bill also can be detrimental to the health of lesbian, gay, and bisexual (LGB) youth.
In March 2017, JAMA Pediatrics published a study on the association between same-sex marriage laws and the rates of suicide attempts.1 Using data from the Youth Risk Behavior Surveillance System, they analyzed the relationship between state policies that permitted same-sex marriage and self-report of suicide attempts within the last 12 months. Thirty percent of LGB youth (13% of the survey population) reported a suicide attempt in the past year prior to any state policies that permitted same-sex marriage, compared with about 9% of the general population. After states implemented pro–same-sex marriage policies, LGB youth suicide attempts dropped to about 26% – a 14% relative decline. This was not limited to LGB youth. The general youth suicide rates declined from 8.6% to 8% – a 7% relative decline. Although the change in suicide attempts was small, the authors determined that the likelihood it occurred by chance was very slim, and concluded that policies enabling same-sex marriage may be associated with an improvement in population health, especially for LGB youth.
This was not the first study examining the relationship between policies and the health of LGB youth. Mark Hatzenbuehler, PhD, of Columbia University, New York, and his associates have published multiple studies on this topic. Four years earlier, Hatzenbuehler et al. published a study on the relationship between antibullying policies and suicide among LGB youth. Using data from the Oregon Healthy Teen survey (2006-2008), he found that LGB youth who live in counties where there are fewer districts with antibullying policies are more than twice as likely to attempt suicide, compared with LGB youth who live in counties where more districts had antibullying policies. Furthermore, the type of antibullying policy mattered. If a district’s antibullying policy did not prohibit bullying based on sexual orientation, then it had no impact on the suicide attempt rates of LGB youth in that area.2 Similar results were found when the relationship between anti–homophobic bullying policies and LGB suicide attempts was examined in the larger Youth Risk Behavior Surveillance System.3
State and local policies also influence other health outcomes among LGB youth. Hatzenbuehler et al. did another study that examined community-level determinants of tobacco use among LGB youth. Again using the data from the Oregon Healthy Teen Survey, they found that LGB youth living in communities that were more supportive of LGB youth (i.e., communities with a high proportion of same-sex couples living in the area, a high proportion of gay-straight alliances at schools, and LGB-specific antibullying policies) were less likely to smoke cigarettes, compared with LGB youth living in communities that were less supportive.4 A similar study in Canada by Konishi et al. found that schools with gay-straight alliances and anti–homophobic bullying policies were less likely to have LGB youth engaging in risky alcohol or illicit drug use.5
Why do these policies matter? A common theme among these policies is that they can either cause or alleviate stress for LGB youth. States that restrict same-sex marriages or schools that do not have any gay-straight alliances may signal to LGB youth that they are not valued or welcomed, or at the very worse, are despised. This creates a hostile and stressful environment for LGB youth, which raises the risk for mental health problems, such as depression and anxiety, which in turn, raises the risk for substance use and suicide.6 Conversely, the presence of a gay-straight alliance at school or a state that allows same-sex marriage may indicate to LGB youth that they are welcomed, if not just tolerated, and may alleviate this risk. Furthermore, antibullying policies seem to reduce the stress associated with bullying among LGB youth because it may serve as a deterrent to bullying based on sexual orientation. Although passing pro-LGB policies will not solve all the health problems among LGB youth, these policies certainly have an impact.
There might be trepidation among some pediatricians about being vocal on a politically charged policy proposal such as H.B. 780. However, suicide and substance use are major concerns for all physicians – especially pediatricians. Policy makers considering passing laws that can affect their LGB constituents should read these studies to see what kind of influence these proposals can have on the health and well-being of LGB youth. Moreover, health care providers should use their expertise, influence, and standing in their community to support policies that encourage protection for LGB youth and oppose policies that can harm LGB youth. These leaders are responsible for ensuring the health of the people they serve.
Dr. Montano is clinical instructor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC.
References
1. JAMA Pediatr. 2017. doi: 10.1001/jamapediatrics.2016.4529.
2. J Adolesc Health. 2013:S21-6. doi: 10.1016/j.jadohealth.2012.08.010.
3. Am J Public Health. 2014. doi: 10.2105/AJPH.2013.301508.
4. Arch Pediatr Adolesc Med. 2011. doi: 10.1001/archpediatrics.2011.64.
5. Prev Med. 2013. doi: 10.1016/j.ypmed.2013.06.031.
6. Psychol Bull. 2003. doi: 10.1037/0033-2909.129.5.674.
Recently North Carolina proposed a bill (House Bill 780) that will ban same-sex marriage in the state, even though the U.S. Supreme Court ruled in 2015 that no states can ban same-sex marriage because doing so violates the 14th Amendment. Although many mainly will argue that H.B. 780 is unconstitutional, this bill also can be detrimental to the health of lesbian, gay, and bisexual (LGB) youth.
In March 2017, JAMA Pediatrics published a study on the association between same-sex marriage laws and the rates of suicide attempts.1 Using data from the Youth Risk Behavior Surveillance System, they analyzed the relationship between state policies that permitted same-sex marriage and self-report of suicide attempts within the last 12 months. Thirty percent of LGB youth (13% of the survey population) reported a suicide attempt in the past year prior to any state policies that permitted same-sex marriage, compared with about 9% of the general population. After states implemented pro–same-sex marriage policies, LGB youth suicide attempts dropped to about 26% – a 14% relative decline. This was not limited to LGB youth. The general youth suicide rates declined from 8.6% to 8% – a 7% relative decline. Although the change in suicide attempts was small, the authors determined that the likelihood it occurred by chance was very slim, and concluded that policies enabling same-sex marriage may be associated with an improvement in population health, especially for LGB youth.
This was not the first study examining the relationship between policies and the health of LGB youth. Mark Hatzenbuehler, PhD, of Columbia University, New York, and his associates have published multiple studies on this topic. Four years earlier, Hatzenbuehler et al. published a study on the relationship between antibullying policies and suicide among LGB youth. Using data from the Oregon Healthy Teen survey (2006-2008), he found that LGB youth who live in counties where there are fewer districts with antibullying policies are more than twice as likely to attempt suicide, compared with LGB youth who live in counties where more districts had antibullying policies. Furthermore, the type of antibullying policy mattered. If a district’s antibullying policy did not prohibit bullying based on sexual orientation, then it had no impact on the suicide attempt rates of LGB youth in that area.2 Similar results were found when the relationship between anti–homophobic bullying policies and LGB suicide attempts was examined in the larger Youth Risk Behavior Surveillance System.3
State and local policies also influence other health outcomes among LGB youth. Hatzenbuehler et al. did another study that examined community-level determinants of tobacco use among LGB youth. Again using the data from the Oregon Healthy Teen Survey, they found that LGB youth living in communities that were more supportive of LGB youth (i.e., communities with a high proportion of same-sex couples living in the area, a high proportion of gay-straight alliances at schools, and LGB-specific antibullying policies) were less likely to smoke cigarettes, compared with LGB youth living in communities that were less supportive.4 A similar study in Canada by Konishi et al. found that schools with gay-straight alliances and anti–homophobic bullying policies were less likely to have LGB youth engaging in risky alcohol or illicit drug use.5
Why do these policies matter? A common theme among these policies is that they can either cause or alleviate stress for LGB youth. States that restrict same-sex marriages or schools that do not have any gay-straight alliances may signal to LGB youth that they are not valued or welcomed, or at the very worse, are despised. This creates a hostile and stressful environment for LGB youth, which raises the risk for mental health problems, such as depression and anxiety, which in turn, raises the risk for substance use and suicide.6 Conversely, the presence of a gay-straight alliance at school or a state that allows same-sex marriage may indicate to LGB youth that they are welcomed, if not just tolerated, and may alleviate this risk. Furthermore, antibullying policies seem to reduce the stress associated with bullying among LGB youth because it may serve as a deterrent to bullying based on sexual orientation. Although passing pro-LGB policies will not solve all the health problems among LGB youth, these policies certainly have an impact.
There might be trepidation among some pediatricians about being vocal on a politically charged policy proposal such as H.B. 780. However, suicide and substance use are major concerns for all physicians – especially pediatricians. Policy makers considering passing laws that can affect their LGB constituents should read these studies to see what kind of influence these proposals can have on the health and well-being of LGB youth. Moreover, health care providers should use their expertise, influence, and standing in their community to support policies that encourage protection for LGB youth and oppose policies that can harm LGB youth. These leaders are responsible for ensuring the health of the people they serve.
Dr. Montano is clinical instructor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC.
References
1. JAMA Pediatr. 2017. doi: 10.1001/jamapediatrics.2016.4529.
2. J Adolesc Health. 2013:S21-6. doi: 10.1016/j.jadohealth.2012.08.010.
3. Am J Public Health. 2014. doi: 10.2105/AJPH.2013.301508.
4. Arch Pediatr Adolesc Med. 2011. doi: 10.1001/archpediatrics.2011.64.
5. Prev Med. 2013. doi: 10.1016/j.ypmed.2013.06.031.
6. Psychol Bull. 2003. doi: 10.1037/0033-2909.129.5.674.
What about the ‘B’ in LGBTQ?
Lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ) youth face bias and discrimination within the health care setting and experience disparities in health, compared with their heterosexual cisgender peers. This is an area that is receiving increasing attention and study as health care providers and researchers work to achieve health equity within these populations.
Studies focusing specifically on the health of bisexual youth and adults are lacking. The few that do exist suggest that the experiences of people who identify as bisexual may be different from those who identify as lesbian or gay. Myths and misconceptions about bisexual, pansexual, queer, and fluid identities may in some cases put these populations at increased risks. Common myths include that bisexuality is just a phase or that youth who identify as bisexual are just confused. Studies suggest that bisexual youth account for almost half of youth who identify as LGBTQ. Understanding more about some of the challenges bisexual youth and adults may face can help us better care for all of our patients and families.
• Bisexual adults are more likely to engage in self-harming behaviors, attempt suicide, or think about suicide than heterosexual adults, lesbian women, or gay men.1
• Bisexual women have higher rates of high blood pressure, compared with heterosexual and lesbian women.2
• Bisexual women have higher rates of alcohol-related disorders than lesbian and heterosexual women.1
Some disparities appear to be related to lack of preventive care. A survey by the Williams Institute found that 39% of bisexual men and 33% of bisexual women did not disclose their sexual orientation, compared with 13% of gay men and 10% of lesbian women.1 The effect of intersecting identities also must be considered when discussing these health disparities. More than 40% of LGBTQ people of color identify as bisexual, and almost half of transgender people describe their sexual orientation as bisexual or queer.1 These individuals may be especially vulnerable to health disparities as they may experience a combination of racism, transphobia, and biphobia.
Risk factors for these disparities may develop early in life. A 2012 survey of LGBTQ youth found that:3
• Bisexual youth were less likely than lesbian and gay youth to report having supportive adults who they could turn to if they were sad.
• Only 5% of bisexual youth reported being very happy, compared with 8% of gay and lesbian youth and 21% of non-LGBT youth.
• Bisexual youth reported higher rates of experimentation with drugs and alcohol, compared with their lesbian, gay, and heterosexual peers.
• Bisexual youth reported lower levels of family acceptance and knowledge of social support systems in their communities than lesbian and gay youth. Both family acceptance and knowledge of social support systems have been identified as protective factors in the development of youth.
• Bisexual youth are less likely to be out to their friends, families, and communities.
As health care providers, recognizing, respecting, and supporting the identities of our bisexual patients is important. A few simple things we can do in practice are as follows:
• Don’t mislabel patients as lesbian, gay, or straight when they have disclosed a bisexual identity.
• Don’t assume that bisexuality is just a phase or that youths are confused when they disclose their identity.
• Don’t assume you know a patient’s sexual orientation or behaviors on the basis of the sex of the current partner or current behaviors.
• Do ask open and nonjudgmental questions about sexual attraction and behaviors, and be familiar with the terms bisexual, queer, questioning, and pansexual in addition to lesbian, gay, and straight.
• Do use inclusive terms like LGBT when referring to the community rather than gay rights.
• Do recognize potential biases and assumptions regarding sexuality and bisexuality and work to change them.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.
Terms and definitions:
Bisexual – A person who can be attracted to more than one sex, gender, or gender identity. “Bi” is often used as an abbreviation.
Biphobia – Prejudice, fear, or hatred directed toward bisexual people.
Queer – A term people often use to express fluid identities and orientations. Historically considered a pejorative term, but used by many youth to describe their identity.
Pansexual – A person who can be attracted to any sex, gender, or gender identity.
References:
1. ”Health Disparities Among Bisexual People,” brief by the Human Rights Campaign Foundation.
2. “New Mexico’s Progress in Collecting Lesbian, Gay, Bisexual, and Transgender Health Data and Its Implications for Addressing Health Disparities,” New Mexico Department of Health, April 2010.
3. “Supporting and Caring for Our Bisexual Youth,” the Human Rights Campaign Foundation, 2014.
Lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ) youth face bias and discrimination within the health care setting and experience disparities in health, compared with their heterosexual cisgender peers. This is an area that is receiving increasing attention and study as health care providers and researchers work to achieve health equity within these populations.
Studies focusing specifically on the health of bisexual youth and adults are lacking. The few that do exist suggest that the experiences of people who identify as bisexual may be different from those who identify as lesbian or gay. Myths and misconceptions about bisexual, pansexual, queer, and fluid identities may in some cases put these populations at increased risks. Common myths include that bisexuality is just a phase or that youth who identify as bisexual are just confused. Studies suggest that bisexual youth account for almost half of youth who identify as LGBTQ. Understanding more about some of the challenges bisexual youth and adults may face can help us better care for all of our patients and families.
• Bisexual adults are more likely to engage in self-harming behaviors, attempt suicide, or think about suicide than heterosexual adults, lesbian women, or gay men.1
• Bisexual women have higher rates of high blood pressure, compared with heterosexual and lesbian women.2
• Bisexual women have higher rates of alcohol-related disorders than lesbian and heterosexual women.1
Some disparities appear to be related to lack of preventive care. A survey by the Williams Institute found that 39% of bisexual men and 33% of bisexual women did not disclose their sexual orientation, compared with 13% of gay men and 10% of lesbian women.1 The effect of intersecting identities also must be considered when discussing these health disparities. More than 40% of LGBTQ people of color identify as bisexual, and almost half of transgender people describe their sexual orientation as bisexual or queer.1 These individuals may be especially vulnerable to health disparities as they may experience a combination of racism, transphobia, and biphobia.
Risk factors for these disparities may develop early in life. A 2012 survey of LGBTQ youth found that:3
• Bisexual youth were less likely than lesbian and gay youth to report having supportive adults who they could turn to if they were sad.
• Only 5% of bisexual youth reported being very happy, compared with 8% of gay and lesbian youth and 21% of non-LGBT youth.
• Bisexual youth reported higher rates of experimentation with drugs and alcohol, compared with their lesbian, gay, and heterosexual peers.
• Bisexual youth reported lower levels of family acceptance and knowledge of social support systems in their communities than lesbian and gay youth. Both family acceptance and knowledge of social support systems have been identified as protective factors in the development of youth.
• Bisexual youth are less likely to be out to their friends, families, and communities.
As health care providers, recognizing, respecting, and supporting the identities of our bisexual patients is important. A few simple things we can do in practice are as follows:
• Don’t mislabel patients as lesbian, gay, or straight when they have disclosed a bisexual identity.
• Don’t assume that bisexuality is just a phase or that youths are confused when they disclose their identity.
• Don’t assume you know a patient’s sexual orientation or behaviors on the basis of the sex of the current partner or current behaviors.
• Do ask open and nonjudgmental questions about sexual attraction and behaviors, and be familiar with the terms bisexual, queer, questioning, and pansexual in addition to lesbian, gay, and straight.
• Do use inclusive terms like LGBT when referring to the community rather than gay rights.
• Do recognize potential biases and assumptions regarding sexuality and bisexuality and work to change them.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.
Terms and definitions:
Bisexual – A person who can be attracted to more than one sex, gender, or gender identity. “Bi” is often used as an abbreviation.
Biphobia – Prejudice, fear, or hatred directed toward bisexual people.
Queer – A term people often use to express fluid identities and orientations. Historically considered a pejorative term, but used by many youth to describe their identity.
Pansexual – A person who can be attracted to any sex, gender, or gender identity.
References:
1. ”Health Disparities Among Bisexual People,” brief by the Human Rights Campaign Foundation.
2. “New Mexico’s Progress in Collecting Lesbian, Gay, Bisexual, and Transgender Health Data and Its Implications for Addressing Health Disparities,” New Mexico Department of Health, April 2010.
3. “Supporting and Caring for Our Bisexual Youth,” the Human Rights Campaign Foundation, 2014.
Lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ) youth face bias and discrimination within the health care setting and experience disparities in health, compared with their heterosexual cisgender peers. This is an area that is receiving increasing attention and study as health care providers and researchers work to achieve health equity within these populations.
Studies focusing specifically on the health of bisexual youth and adults are lacking. The few that do exist suggest that the experiences of people who identify as bisexual may be different from those who identify as lesbian or gay. Myths and misconceptions about bisexual, pansexual, queer, and fluid identities may in some cases put these populations at increased risks. Common myths include that bisexuality is just a phase or that youth who identify as bisexual are just confused. Studies suggest that bisexual youth account for almost half of youth who identify as LGBTQ. Understanding more about some of the challenges bisexual youth and adults may face can help us better care for all of our patients and families.
• Bisexual adults are more likely to engage in self-harming behaviors, attempt suicide, or think about suicide than heterosexual adults, lesbian women, or gay men.1
• Bisexual women have higher rates of high blood pressure, compared with heterosexual and lesbian women.2
• Bisexual women have higher rates of alcohol-related disorders than lesbian and heterosexual women.1
Some disparities appear to be related to lack of preventive care. A survey by the Williams Institute found that 39% of bisexual men and 33% of bisexual women did not disclose their sexual orientation, compared with 13% of gay men and 10% of lesbian women.1 The effect of intersecting identities also must be considered when discussing these health disparities. More than 40% of LGBTQ people of color identify as bisexual, and almost half of transgender people describe their sexual orientation as bisexual or queer.1 These individuals may be especially vulnerable to health disparities as they may experience a combination of racism, transphobia, and biphobia.
Risk factors for these disparities may develop early in life. A 2012 survey of LGBTQ youth found that:3
• Bisexual youth were less likely than lesbian and gay youth to report having supportive adults who they could turn to if they were sad.
• Only 5% of bisexual youth reported being very happy, compared with 8% of gay and lesbian youth and 21% of non-LGBT youth.
• Bisexual youth reported higher rates of experimentation with drugs and alcohol, compared with their lesbian, gay, and heterosexual peers.
• Bisexual youth reported lower levels of family acceptance and knowledge of social support systems in their communities than lesbian and gay youth. Both family acceptance and knowledge of social support systems have been identified as protective factors in the development of youth.
• Bisexual youth are less likely to be out to their friends, families, and communities.
As health care providers, recognizing, respecting, and supporting the identities of our bisexual patients is important. A few simple things we can do in practice are as follows:
• Don’t mislabel patients as lesbian, gay, or straight when they have disclosed a bisexual identity.
• Don’t assume that bisexuality is just a phase or that youths are confused when they disclose their identity.
• Don’t assume you know a patient’s sexual orientation or behaviors on the basis of the sex of the current partner or current behaviors.
• Do ask open and nonjudgmental questions about sexual attraction and behaviors, and be familiar with the terms bisexual, queer, questioning, and pansexual in addition to lesbian, gay, and straight.
• Do use inclusive terms like LGBT when referring to the community rather than gay rights.
• Do recognize potential biases and assumptions regarding sexuality and bisexuality and work to change them.
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.
Terms and definitions:
Bisexual – A person who can be attracted to more than one sex, gender, or gender identity. “Bi” is often used as an abbreviation.
Biphobia – Prejudice, fear, or hatred directed toward bisexual people.
Queer – A term people often use to express fluid identities and orientations. Historically considered a pejorative term, but used by many youth to describe their identity.
Pansexual – A person who can be attracted to any sex, gender, or gender identity.
References:
1. ”Health Disparities Among Bisexual People,” brief by the Human Rights Campaign Foundation.
2. “New Mexico’s Progress in Collecting Lesbian, Gay, Bisexual, and Transgender Health Data and Its Implications for Addressing Health Disparities,” New Mexico Department of Health, April 2010.
3. “Supporting and Caring for Our Bisexual Youth,” the Human Rights Campaign Foundation, 2014.
Eating disorders in transgender youth
The field of transgender health is growing. What began as a lone German physician in 1918 defying the norms of treating gender identity as a disease now has burgeoned into a field that includes 1,079 PubMed articles,two medical guidelines1,2, and a multitude of books. As we learn more about the complexity of gender and gender identity, we also are discovering potential problems that occur when providing care to our transgender patients. One is eating disorders.
A systematic review by Jones et al. showed only a handful of studies on eating disorders in transgender individuals, most of them restricted to case studies.3 In some situations, the issue of gender identity arises during treatment for an eating disorder, as the individual realizes that body dissatisfaction is due to the gender identity instead of a fear of gaining weight. In other cases, a transgender person in the process of transitioning to the affirmed gender develops an eating disorder.
There are two larger quantitative studies on eating disorders among transgender individuals. One study of 289,024 college students reveals that transgender students, compared to cisgender students, are almost five times as likely to report an eating disorder and two times as likely to use unhealthy compensatory methods (e.g., vomiting) for weight control.4 Another study of almost 2,500 teenagers shows that transgender individuals are almost three times as likely to restrict their eating, almost nine times as likely to take diet pills, and seven times as likely to take laxatives.5
The most commonly suggested reason for the possible elevated risk for eating disorders among transgender individuals is that many of them are trying to achieve the unrealistic standards of the ideal masculine or feminine body type. Another explanation is that eating disorders among transgender individuals are maladaptive coping mechanisms to stress from antitrans stigma and discrimination.4 However, these explanations are not mutually exclusive and could simultaneously drive disordered eating among transgender individuals.
To further appreciate the relationship between these two conditions, one must understand their similarities and differences. The Diagnostic Statistical Manual of Mental Disorders V characterizes eating disorders as “a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and ... significantly impairs physical health or psychosocial functioning.”6 Anorexia nervosa and bulimia nervosa are driven by fear of gaining weight or by a self-esteem unduly influenced by weight or appearance.6
Gender dysphoria, in comparison, is the distress caused by the incongruence between one’s gender identity and one’s anatomy, along with the desire to have the characteristics of one’s affirmed gender identity. This condition also could severely alter physical and psychosocial functioning,7 partly because of the distress from the incongruence, and partly because of the stress from antitrans stigma and discrimination, as an individual attempts to match the body with the gender identity8 (e.g., wearing clothing to match the gender identity).
The higher risk of developing an eating disorder among transgender individuals makes sense. Dissatisfaction with one’s body characterizes both conditions. The high standards on what is masculine or feminine affects everyone, especially transgender individuals who may feel that they’re “far behind” when they begin to transition to their affirmed gender. In addition, both involve identity. Those who have anorexia nervosa also incorporate this into their own identity.9 This is why treating an eating disorder can be very difficult.
Finally, individuals afflicted by an eating disorder or gender dysphoria engage in certain behaviors to achieve their desired appearance. However, this is where the similarities end. One major distinction between an eating disorder and gender dysphoria is the treatment approach. The goal in treating an eating disorder is to discourage the disordered behavior and encourage healthier eating habits and a more positive body image. Affirming the identity of someone with an eating disorder can be deadly, as it will encourage more disordered eating.10 In contrast, affirming the identity of someone with gender dysphoria through social transition, cross-sex hormones, and/or surgical reassignment is life-saving and therapeutic.11
There is little guidance on how to treat the these disorders simultaneously. What complicates treating both conditions at the same time is that when an eating disorder is accompanied by another mental health disorder (e.g., substance use), one condition over the other is prioritized.12 There is no guidance on whether the eating disorder or gender dysphoria should take priority over the other, or if it is possible to treat both conditions at the same time.
Strandjord et al. suggest a hierarchal approach, in which life-threatening issues (such as suicide or electrolyte disturbances) take priority.13 In addition, if the patient is malnourished, weight restoration should be the initial focus. A patient who is severely malnourished may not have the cognitive capacity nor the physiological ability to manage comorbidities such as anxiety or depression,12 much less have the capacity to process something as complex as gender and gender identity, nor understand the steps necessary for a successful transition to the affirmed gender. However, this does not mean providers should wait to successfully manage an eating disorder before addressing gender dysphoria. Studies have suggested that gender-affirming medical therapies (e.g., cross sex hormones) can be therapeutic for both gender dysphoria and eating disorder symptoms.14 Finally, because of the two ways a transgender patient with an eating disorder can present, I recommend screening for eating disorders in transgender individuals and inquiring about gender identity among those with an eating disorder. Doing so may save a life.
References
1. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
2. Adv Urol. 2012;2012:581712.
3. Int Rev Psychiatry. 2016;28(1):81-94.
4. J Adolesc Health. 2015 Aug;57(2):144-9.
5. J Adolesc Health. 2016. doi: 10.1016/j.jadohealth.2016.08.027.
6. Feeding and Eating Disorders. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).
7. Gender Dysphoria. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).
8. Psychol Bull. 2003 Sep;129(5):674-97.
9. Int J Law Psychiatry. 2003 Sep-Oct;26(5):533-48.
10. Arch Gen Psychiatry. 2011 Jul;68(7):724-31.
11. Clin Endocrinol (Oxf). 2010 Feb;72(2):214-31.
12. CNS drugs. 2006;20(8):655-63.
13. Int J Eat Disord. 2015 Nov;48(7):942-5.
14. Eat Disord. 2012;20(4):300-11.
The field of transgender health is growing. What began as a lone German physician in 1918 defying the norms of treating gender identity as a disease now has burgeoned into a field that includes 1,079 PubMed articles,two medical guidelines1,2, and a multitude of books. As we learn more about the complexity of gender and gender identity, we also are discovering potential problems that occur when providing care to our transgender patients. One is eating disorders.
A systematic review by Jones et al. showed only a handful of studies on eating disorders in transgender individuals, most of them restricted to case studies.3 In some situations, the issue of gender identity arises during treatment for an eating disorder, as the individual realizes that body dissatisfaction is due to the gender identity instead of a fear of gaining weight. In other cases, a transgender person in the process of transitioning to the affirmed gender develops an eating disorder.
There are two larger quantitative studies on eating disorders among transgender individuals. One study of 289,024 college students reveals that transgender students, compared to cisgender students, are almost five times as likely to report an eating disorder and two times as likely to use unhealthy compensatory methods (e.g., vomiting) for weight control.4 Another study of almost 2,500 teenagers shows that transgender individuals are almost three times as likely to restrict their eating, almost nine times as likely to take diet pills, and seven times as likely to take laxatives.5
The most commonly suggested reason for the possible elevated risk for eating disorders among transgender individuals is that many of them are trying to achieve the unrealistic standards of the ideal masculine or feminine body type. Another explanation is that eating disorders among transgender individuals are maladaptive coping mechanisms to stress from antitrans stigma and discrimination.4 However, these explanations are not mutually exclusive and could simultaneously drive disordered eating among transgender individuals.
To further appreciate the relationship between these two conditions, one must understand their similarities and differences. The Diagnostic Statistical Manual of Mental Disorders V characterizes eating disorders as “a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and ... significantly impairs physical health or psychosocial functioning.”6 Anorexia nervosa and bulimia nervosa are driven by fear of gaining weight or by a self-esteem unduly influenced by weight or appearance.6
Gender dysphoria, in comparison, is the distress caused by the incongruence between one’s gender identity and one’s anatomy, along with the desire to have the characteristics of one’s affirmed gender identity. This condition also could severely alter physical and psychosocial functioning,7 partly because of the distress from the incongruence, and partly because of the stress from antitrans stigma and discrimination, as an individual attempts to match the body with the gender identity8 (e.g., wearing clothing to match the gender identity).
The higher risk of developing an eating disorder among transgender individuals makes sense. Dissatisfaction with one’s body characterizes both conditions. The high standards on what is masculine or feminine affects everyone, especially transgender individuals who may feel that they’re “far behind” when they begin to transition to their affirmed gender. In addition, both involve identity. Those who have anorexia nervosa also incorporate this into their own identity.9 This is why treating an eating disorder can be very difficult.
Finally, individuals afflicted by an eating disorder or gender dysphoria engage in certain behaviors to achieve their desired appearance. However, this is where the similarities end. One major distinction between an eating disorder and gender dysphoria is the treatment approach. The goal in treating an eating disorder is to discourage the disordered behavior and encourage healthier eating habits and a more positive body image. Affirming the identity of someone with an eating disorder can be deadly, as it will encourage more disordered eating.10 In contrast, affirming the identity of someone with gender dysphoria through social transition, cross-sex hormones, and/or surgical reassignment is life-saving and therapeutic.11
There is little guidance on how to treat the these disorders simultaneously. What complicates treating both conditions at the same time is that when an eating disorder is accompanied by another mental health disorder (e.g., substance use), one condition over the other is prioritized.12 There is no guidance on whether the eating disorder or gender dysphoria should take priority over the other, or if it is possible to treat both conditions at the same time.
Strandjord et al. suggest a hierarchal approach, in which life-threatening issues (such as suicide or electrolyte disturbances) take priority.13 In addition, if the patient is malnourished, weight restoration should be the initial focus. A patient who is severely malnourished may not have the cognitive capacity nor the physiological ability to manage comorbidities such as anxiety or depression,12 much less have the capacity to process something as complex as gender and gender identity, nor understand the steps necessary for a successful transition to the affirmed gender. However, this does not mean providers should wait to successfully manage an eating disorder before addressing gender dysphoria. Studies have suggested that gender-affirming medical therapies (e.g., cross sex hormones) can be therapeutic for both gender dysphoria and eating disorder symptoms.14 Finally, because of the two ways a transgender patient with an eating disorder can present, I recommend screening for eating disorders in transgender individuals and inquiring about gender identity among those with an eating disorder. Doing so may save a life.
References
1. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
2. Adv Urol. 2012;2012:581712.
3. Int Rev Psychiatry. 2016;28(1):81-94.
4. J Adolesc Health. 2015 Aug;57(2):144-9.
5. J Adolesc Health. 2016. doi: 10.1016/j.jadohealth.2016.08.027.
6. Feeding and Eating Disorders. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).
7. Gender Dysphoria. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).
8. Psychol Bull. 2003 Sep;129(5):674-97.
9. Int J Law Psychiatry. 2003 Sep-Oct;26(5):533-48.
10. Arch Gen Psychiatry. 2011 Jul;68(7):724-31.
11. Clin Endocrinol (Oxf). 2010 Feb;72(2):214-31.
12. CNS drugs. 2006;20(8):655-63.
13. Int J Eat Disord. 2015 Nov;48(7):942-5.
14. Eat Disord. 2012;20(4):300-11.
The field of transgender health is growing. What began as a lone German physician in 1918 defying the norms of treating gender identity as a disease now has burgeoned into a field that includes 1,079 PubMed articles,two medical guidelines1,2, and a multitude of books. As we learn more about the complexity of gender and gender identity, we also are discovering potential problems that occur when providing care to our transgender patients. One is eating disorders.
A systematic review by Jones et al. showed only a handful of studies on eating disorders in transgender individuals, most of them restricted to case studies.3 In some situations, the issue of gender identity arises during treatment for an eating disorder, as the individual realizes that body dissatisfaction is due to the gender identity instead of a fear of gaining weight. In other cases, a transgender person in the process of transitioning to the affirmed gender develops an eating disorder.
There are two larger quantitative studies on eating disorders among transgender individuals. One study of 289,024 college students reveals that transgender students, compared to cisgender students, are almost five times as likely to report an eating disorder and two times as likely to use unhealthy compensatory methods (e.g., vomiting) for weight control.4 Another study of almost 2,500 teenagers shows that transgender individuals are almost three times as likely to restrict their eating, almost nine times as likely to take diet pills, and seven times as likely to take laxatives.5
The most commonly suggested reason for the possible elevated risk for eating disorders among transgender individuals is that many of them are trying to achieve the unrealistic standards of the ideal masculine or feminine body type. Another explanation is that eating disorders among transgender individuals are maladaptive coping mechanisms to stress from antitrans stigma and discrimination.4 However, these explanations are not mutually exclusive and could simultaneously drive disordered eating among transgender individuals.
To further appreciate the relationship between these two conditions, one must understand their similarities and differences. The Diagnostic Statistical Manual of Mental Disorders V characterizes eating disorders as “a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and ... significantly impairs physical health or psychosocial functioning.”6 Anorexia nervosa and bulimia nervosa are driven by fear of gaining weight or by a self-esteem unduly influenced by weight or appearance.6
Gender dysphoria, in comparison, is the distress caused by the incongruence between one’s gender identity and one’s anatomy, along with the desire to have the characteristics of one’s affirmed gender identity. This condition also could severely alter physical and psychosocial functioning,7 partly because of the distress from the incongruence, and partly because of the stress from antitrans stigma and discrimination, as an individual attempts to match the body with the gender identity8 (e.g., wearing clothing to match the gender identity).
The higher risk of developing an eating disorder among transgender individuals makes sense. Dissatisfaction with one’s body characterizes both conditions. The high standards on what is masculine or feminine affects everyone, especially transgender individuals who may feel that they’re “far behind” when they begin to transition to their affirmed gender. In addition, both involve identity. Those who have anorexia nervosa also incorporate this into their own identity.9 This is why treating an eating disorder can be very difficult.
Finally, individuals afflicted by an eating disorder or gender dysphoria engage in certain behaviors to achieve their desired appearance. However, this is where the similarities end. One major distinction between an eating disorder and gender dysphoria is the treatment approach. The goal in treating an eating disorder is to discourage the disordered behavior and encourage healthier eating habits and a more positive body image. Affirming the identity of someone with an eating disorder can be deadly, as it will encourage more disordered eating.10 In contrast, affirming the identity of someone with gender dysphoria through social transition, cross-sex hormones, and/or surgical reassignment is life-saving and therapeutic.11
There is little guidance on how to treat the these disorders simultaneously. What complicates treating both conditions at the same time is that when an eating disorder is accompanied by another mental health disorder (e.g., substance use), one condition over the other is prioritized.12 There is no guidance on whether the eating disorder or gender dysphoria should take priority over the other, or if it is possible to treat both conditions at the same time.
Strandjord et al. suggest a hierarchal approach, in which life-threatening issues (such as suicide or electrolyte disturbances) take priority.13 In addition, if the patient is malnourished, weight restoration should be the initial focus. A patient who is severely malnourished may not have the cognitive capacity nor the physiological ability to manage comorbidities such as anxiety or depression,12 much less have the capacity to process something as complex as gender and gender identity, nor understand the steps necessary for a successful transition to the affirmed gender. However, this does not mean providers should wait to successfully manage an eating disorder before addressing gender dysphoria. Studies have suggested that gender-affirming medical therapies (e.g., cross sex hormones) can be therapeutic for both gender dysphoria and eating disorder symptoms.14 Finally, because of the two ways a transgender patient with an eating disorder can present, I recommend screening for eating disorders in transgender individuals and inquiring about gender identity among those with an eating disorder. Doing so may save a life.
References
1. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
2. Adv Urol. 2012;2012:581712.
3. Int Rev Psychiatry. 2016;28(1):81-94.
4. J Adolesc Health. 2015 Aug;57(2):144-9.
5. J Adolesc Health. 2016. doi: 10.1016/j.jadohealth.2016.08.027.
6. Feeding and Eating Disorders. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).
7. Gender Dysphoria. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).
8. Psychol Bull. 2003 Sep;129(5):674-97.
9. Int J Law Psychiatry. 2003 Sep-Oct;26(5):533-48.
10. Arch Gen Psychiatry. 2011 Jul;68(7):724-31.
11. Clin Endocrinol (Oxf). 2010 Feb;72(2):214-31.
12. CNS drugs. 2006;20(8):655-63.
13. Int J Eat Disord. 2015 Nov;48(7):942-5.
14. Eat Disord. 2012;20(4):300-11.