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Seven myths about sex and relationships in LGBT youth
Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.
Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:
Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.1
Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.2
Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.3 This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.
Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.
Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.4 However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.
Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,5 but don’t forget that young lesbian women may have had sex with men.
Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.6 Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.
Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.
Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.
Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.7
Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,8 because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.9
So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.
The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:
• Ask, “Are your sexual partner’s male, female, or both?”
• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”
• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”
• Ask, “Have you ever had an STI, and if so, how was it treated?”
• Ask, “What do you use for birth control?” either hormonal or barrier methods.
In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.
Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”
By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.
Here are some resources on sex and relationships in LGBT youth:
• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.
• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.
• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.
References
2. National Transgender Discrimination Survey: Full Report. 2012.
3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.
4. J Youth Adolesc. 2015 Jan;44(1):211-24.
5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7.
6. Sex Transm Dis. 2010 May;37(5):335-9.
7. Sexpress: The Toronto teen survey report. 2009.
8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.
9. Can J Hum Sex. 2008;17(3):123-139.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.
Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.
Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:
Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.1
Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.2
Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.3 This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.
Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.
Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.4 However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.
Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,5 but don’t forget that young lesbian women may have had sex with men.
Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.6 Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.
Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.
Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.
Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.7
Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,8 because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.9
So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.
The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:
• Ask, “Are your sexual partner’s male, female, or both?”
• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”
• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”
• Ask, “Have you ever had an STI, and if so, how was it treated?”
• Ask, “What do you use for birth control?” either hormonal or barrier methods.
In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.
Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”
By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.
Here are some resources on sex and relationships in LGBT youth:
• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.
• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.
• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.
References
2. National Transgender Discrimination Survey: Full Report. 2012.
3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.
4. J Youth Adolesc. 2015 Jan;44(1):211-24.
5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7.
6. Sex Transm Dis. 2010 May;37(5):335-9.
7. Sexpress: The Toronto teen survey report. 2009.
8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.
9. Can J Hum Sex. 2008;17(3):123-139.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.
Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.
Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:
Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.1
Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.2
Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.3 This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.
Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.
Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.4 However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.
Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,5 but don’t forget that young lesbian women may have had sex with men.
Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.6 Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.
Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.
Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.
Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.7
Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,8 because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.9
So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.
The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:
• Ask, “Are your sexual partner’s male, female, or both?”
• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”
• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”
• Ask, “Have you ever had an STI, and if so, how was it treated?”
• Ask, “What do you use for birth control?” either hormonal or barrier methods.
In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.
Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”
By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.
Here are some resources on sex and relationships in LGBT youth:
• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.
• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.
• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.
References
2. National Transgender Discrimination Survey: Full Report. 2012.
3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.
4. J Youth Adolesc. 2015 Jan;44(1):211-24.
5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7.
6. Sex Transm Dis. 2010 May;37(5):335-9.
7. Sexpress: The Toronto teen survey report. 2009.
8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.
9. Can J Hum Sex. 2008;17(3):123-139.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.
Caring for gender-nonconforming youth in a primary care setting – Part 2
Gender identity typically develops in early childhood, and by age 4 years, most children consistently refer to themselves as a girl or a boy.1 For the majority of children, natal sex or sex assigned at birth, aligns with gender identity (a person’s innate sense of feeling male, female, or somewhere in between). However, this is not always the case. Gender identity can be understood as a spectrum with youth identifying as a gender that aligns with their natal sex (cisgender), is opposite of their natal sex (transgender), no gender (agender), or somewhere in between (genderqueer). The distress that can result from an incongruence between natal sex and gender identity is called gender dysphoria. Youth with gender dysphoria are at increased risk for a number of conditions, including suicide and self-harm. Early identification and appropriate care of these youth can reduce these risks. This month’s column will briefly review assessment of these youth in the pediatric setting.
Many youth who have a gender-nonconforming identity in childhood will not go on to have one in adulthood.2,3 Those who have a consistent, insistent, and persistent nonconforming identity are more likely to have this identity persist into adulthood. Youth who experience increased gender dysphoria with the onset of puberty rarely have this subside.
As it can be difficult to predict the trajectory of gender identity from childhood to adolescence, the approach to the prepubertal and pubertal gender nonconforming patient is different. It is important to note that research suggests that gender identity is innate and cannot be changed with interventions. The goals of care for gender-nonconforming (GN) youth include providing a safe environment where youth can explore their identities, and individualizing treatment to meet the needs of each patient and family.
Care for prepubertal GN youth
For parents:
Have you noticed, or are you concerned about your child’s:
• Preference or rejection of particular toys/games?
• Hair and clothing preferences or rejections?
• Preferred (if any) gender of playmates?
Has your child ever expressed:
• A desire to be or insistence that they are the other gender?
• A dislike of their sexual anatomy?
• A desire for primary (penis, vagina) or secondary (periods, facial hair) sex characteristics of the other gender?
Are you concerned about bullying ?
Do you have any concerns about your child’s mood or concerns for self-harm?
For children:
• Do you feel more like a girl, boy, neither, both?
• How would you like to play, cut your hair, dress?
• What name or pronoun (she for girl, he for boy) fits you?4
The goal for prepubertal youth with nonconforming identities is to ensure that they are safe at home, school, and at play. Some youth may express a desire to “transition” or live as their identified gender by changing their name and dressing as their identified gender. Some youth and families may choose to transition only in certain settings (at home, but not at school). Some youth and families may want a safe space where the child can grow, develop, and continue to explore their identity without transitioning. Mental health providers trained in the care of GN youth can help patients and families decide if transition is appropriate for them and support them with the process and timing of transitioning. For youth who experience depression, anxiety, bullying, or thoughts of self-harm related to their gender identity, care by an experienced mental health provider is essential. It is important to recognize that each patient and family will need an individualized approach based on their needs.
Care for pubertal GN youth
The development of secondary sex characteristics can be particularly distressing for GN youth. Some youth may first experience gender dysphoria at this time. This distress combined with the psychosocial stressors of adolescent development can lead to depression, anxiety, suicidal ideation, self-harm, and other risk taking behaviors. Visits with pubertal GN youth, as with any adolescent, should include confidential time alone with the medical provider to discuss any concerns. Youth should be informed that information will be kept confidential, but parents will need to be notified of any safety concerns (such as suicidality or self-harm). As with prepubertal youth, a history related to hair and clothing preferences; distress related to genital anatomy; and the desire to be the other gender should be obtained. A pubertal history and any related symptoms of distress also should be obtained.
DO
• Ask preferred name and pronoun.
• Perform confidential strength and risk assessment.
• Assess for family and social support.
• Refer to appropriate mental health and transgender providers.
DON’T
• Assume names and pronouns.
• Interview patient only with parent in the room.
• Disclose identity without patient consent.
• Dismiss parents as sources of support.
• Refer for reparative therapy.4
Youth who are suspected to have a diagnosis of gender dysphoria should be referred to mental health and medical providers with experience caring for transgender youth. These specialists can work with patients and families, and determine when and if youth are eligible for puberty blocking therapy with GnRH analogues and/or hormone therapy. GnRH analogues, if appropriate, can be prescribed after patients have reached sexual maturity rating stage 2. The rationale for this treatment is to prevent the development of unwanted secondary sex characteristics while giving the youth a chance to continue with psychotherapy and explore their gender identity.5 Hormone therapy, if appropriate, can be prescribed a few years later under the care of a transgender specialist and mental health provider.
Summary
It is normal to experiment with gender roles and expression in childhood. Providing a safe space to do this is important.
Individuals who have a persistent, consistent, and insistent gender-nonconforming identification and who have increased distress with puberty are unlikely to have this subside.
Pediatricians can assess for gender dysphoria and screen for related mood disorders and behaviors in the primary care setting. Appropriate referral to trained professionals is important.
Care should be individualized and focused on the health and safety of the patient.
Resources
For health care professionals
• World Professional Association for Transgender Health: Standards of care on care of transgender patients and provider directory. www.wpath.org• Physicians for Reproductive Health’s adolescent reproductive and sexual health education program (ARSHEP): Best practices for adolescent and reproductive health: Module on caring for transgender adolescent patients. prh.org/teen-reproductive-health/arshep-downloads/
For patients and families
• Family Acceptance Project: familyproject.sfsu.edu/
• Healthychildren.org: Parenting website supported by the American Academy of Pediatrics. Links to articles on gender nonconforming and transgender children; gender identity development in children. www.healthychildren.org
References
1. Caring for Your School Age Child: Ages 5-12 by the American Academy of Pediatrics (New York: Bantam Books, 1995).
2. Dev Psychol. 2008 Jan;44(1):34-45.
3. J Am Acad Child and Adolesc Psychiatry. 2008;47(12):1413-23
4. Caring for Transgender Adolescent Patients. Physicians for Reproductive Health’s Adolescent Reproductive and Sexual Health Education Program (ARSHEP): Best practices for adolescent and reproductive health: prh.org/teen-reproductive-health/arshep-downloads/
5. World Professional Association of Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th Edition (International Journal of Transgenderism. 2011;13:165-232)
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.
Gender identity typically develops in early childhood, and by age 4 years, most children consistently refer to themselves as a girl or a boy.1 For the majority of children, natal sex or sex assigned at birth, aligns with gender identity (a person’s innate sense of feeling male, female, or somewhere in between). However, this is not always the case. Gender identity can be understood as a spectrum with youth identifying as a gender that aligns with their natal sex (cisgender), is opposite of their natal sex (transgender), no gender (agender), or somewhere in between (genderqueer). The distress that can result from an incongruence between natal sex and gender identity is called gender dysphoria. Youth with gender dysphoria are at increased risk for a number of conditions, including suicide and self-harm. Early identification and appropriate care of these youth can reduce these risks. This month’s column will briefly review assessment of these youth in the pediatric setting.
Many youth who have a gender-nonconforming identity in childhood will not go on to have one in adulthood.2,3 Those who have a consistent, insistent, and persistent nonconforming identity are more likely to have this identity persist into adulthood. Youth who experience increased gender dysphoria with the onset of puberty rarely have this subside.
As it can be difficult to predict the trajectory of gender identity from childhood to adolescence, the approach to the prepubertal and pubertal gender nonconforming patient is different. It is important to note that research suggests that gender identity is innate and cannot be changed with interventions. The goals of care for gender-nonconforming (GN) youth include providing a safe environment where youth can explore their identities, and individualizing treatment to meet the needs of each patient and family.
Care for prepubertal GN youth
For parents:
Have you noticed, or are you concerned about your child’s:
• Preference or rejection of particular toys/games?
• Hair and clothing preferences or rejections?
• Preferred (if any) gender of playmates?
Has your child ever expressed:
• A desire to be or insistence that they are the other gender?
• A dislike of their sexual anatomy?
• A desire for primary (penis, vagina) or secondary (periods, facial hair) sex characteristics of the other gender?
Are you concerned about bullying ?
Do you have any concerns about your child’s mood or concerns for self-harm?
For children:
• Do you feel more like a girl, boy, neither, both?
• How would you like to play, cut your hair, dress?
• What name or pronoun (she for girl, he for boy) fits you?4
The goal for prepubertal youth with nonconforming identities is to ensure that they are safe at home, school, and at play. Some youth may express a desire to “transition” or live as their identified gender by changing their name and dressing as their identified gender. Some youth and families may choose to transition only in certain settings (at home, but not at school). Some youth and families may want a safe space where the child can grow, develop, and continue to explore their identity without transitioning. Mental health providers trained in the care of GN youth can help patients and families decide if transition is appropriate for them and support them with the process and timing of transitioning. For youth who experience depression, anxiety, bullying, or thoughts of self-harm related to their gender identity, care by an experienced mental health provider is essential. It is important to recognize that each patient and family will need an individualized approach based on their needs.
Care for pubertal GN youth
The development of secondary sex characteristics can be particularly distressing for GN youth. Some youth may first experience gender dysphoria at this time. This distress combined with the psychosocial stressors of adolescent development can lead to depression, anxiety, suicidal ideation, self-harm, and other risk taking behaviors. Visits with pubertal GN youth, as with any adolescent, should include confidential time alone with the medical provider to discuss any concerns. Youth should be informed that information will be kept confidential, but parents will need to be notified of any safety concerns (such as suicidality or self-harm). As with prepubertal youth, a history related to hair and clothing preferences; distress related to genital anatomy; and the desire to be the other gender should be obtained. A pubertal history and any related symptoms of distress also should be obtained.
DO
• Ask preferred name and pronoun.
• Perform confidential strength and risk assessment.
• Assess for family and social support.
• Refer to appropriate mental health and transgender providers.
DON’T
• Assume names and pronouns.
• Interview patient only with parent in the room.
• Disclose identity without patient consent.
• Dismiss parents as sources of support.
• Refer for reparative therapy.4
Youth who are suspected to have a diagnosis of gender dysphoria should be referred to mental health and medical providers with experience caring for transgender youth. These specialists can work with patients and families, and determine when and if youth are eligible for puberty blocking therapy with GnRH analogues and/or hormone therapy. GnRH analogues, if appropriate, can be prescribed after patients have reached sexual maturity rating stage 2. The rationale for this treatment is to prevent the development of unwanted secondary sex characteristics while giving the youth a chance to continue with psychotherapy and explore their gender identity.5 Hormone therapy, if appropriate, can be prescribed a few years later under the care of a transgender specialist and mental health provider.
Summary
It is normal to experiment with gender roles and expression in childhood. Providing a safe space to do this is important.
Individuals who have a persistent, consistent, and insistent gender-nonconforming identification and who have increased distress with puberty are unlikely to have this subside.
Pediatricians can assess for gender dysphoria and screen for related mood disorders and behaviors in the primary care setting. Appropriate referral to trained professionals is important.
Care should be individualized and focused on the health and safety of the patient.
Resources
For health care professionals
• World Professional Association for Transgender Health: Standards of care on care of transgender patients and provider directory. www.wpath.org• Physicians for Reproductive Health’s adolescent reproductive and sexual health education program (ARSHEP): Best practices for adolescent and reproductive health: Module on caring for transgender adolescent patients. prh.org/teen-reproductive-health/arshep-downloads/
For patients and families
• Family Acceptance Project: familyproject.sfsu.edu/
• Healthychildren.org: Parenting website supported by the American Academy of Pediatrics. Links to articles on gender nonconforming and transgender children; gender identity development in children. www.healthychildren.org
References
1. Caring for Your School Age Child: Ages 5-12 by the American Academy of Pediatrics (New York: Bantam Books, 1995).
2. Dev Psychol. 2008 Jan;44(1):34-45.
3. J Am Acad Child and Adolesc Psychiatry. 2008;47(12):1413-23
4. Caring for Transgender Adolescent Patients. Physicians for Reproductive Health’s Adolescent Reproductive and Sexual Health Education Program (ARSHEP): Best practices for adolescent and reproductive health: prh.org/teen-reproductive-health/arshep-downloads/
5. World Professional Association of Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th Edition (International Journal of Transgenderism. 2011;13:165-232)
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.
Gender identity typically develops in early childhood, and by age 4 years, most children consistently refer to themselves as a girl or a boy.1 For the majority of children, natal sex or sex assigned at birth, aligns with gender identity (a person’s innate sense of feeling male, female, or somewhere in between). However, this is not always the case. Gender identity can be understood as a spectrum with youth identifying as a gender that aligns with their natal sex (cisgender), is opposite of their natal sex (transgender), no gender (agender), or somewhere in between (genderqueer). The distress that can result from an incongruence between natal sex and gender identity is called gender dysphoria. Youth with gender dysphoria are at increased risk for a number of conditions, including suicide and self-harm. Early identification and appropriate care of these youth can reduce these risks. This month’s column will briefly review assessment of these youth in the pediatric setting.
Many youth who have a gender-nonconforming identity in childhood will not go on to have one in adulthood.2,3 Those who have a consistent, insistent, and persistent nonconforming identity are more likely to have this identity persist into adulthood. Youth who experience increased gender dysphoria with the onset of puberty rarely have this subside.
As it can be difficult to predict the trajectory of gender identity from childhood to adolescence, the approach to the prepubertal and pubertal gender nonconforming patient is different. It is important to note that research suggests that gender identity is innate and cannot be changed with interventions. The goals of care for gender-nonconforming (GN) youth include providing a safe environment where youth can explore their identities, and individualizing treatment to meet the needs of each patient and family.
Care for prepubertal GN youth
For parents:
Have you noticed, or are you concerned about your child’s:
• Preference or rejection of particular toys/games?
• Hair and clothing preferences or rejections?
• Preferred (if any) gender of playmates?
Has your child ever expressed:
• A desire to be or insistence that they are the other gender?
• A dislike of their sexual anatomy?
• A desire for primary (penis, vagina) or secondary (periods, facial hair) sex characteristics of the other gender?
Are you concerned about bullying ?
Do you have any concerns about your child’s mood or concerns for self-harm?
For children:
• Do you feel more like a girl, boy, neither, both?
• How would you like to play, cut your hair, dress?
• What name or pronoun (she for girl, he for boy) fits you?4
The goal for prepubertal youth with nonconforming identities is to ensure that they are safe at home, school, and at play. Some youth may express a desire to “transition” or live as their identified gender by changing their name and dressing as their identified gender. Some youth and families may choose to transition only in certain settings (at home, but not at school). Some youth and families may want a safe space where the child can grow, develop, and continue to explore their identity without transitioning. Mental health providers trained in the care of GN youth can help patients and families decide if transition is appropriate for them and support them with the process and timing of transitioning. For youth who experience depression, anxiety, bullying, or thoughts of self-harm related to their gender identity, care by an experienced mental health provider is essential. It is important to recognize that each patient and family will need an individualized approach based on their needs.
Care for pubertal GN youth
The development of secondary sex characteristics can be particularly distressing for GN youth. Some youth may first experience gender dysphoria at this time. This distress combined with the psychosocial stressors of adolescent development can lead to depression, anxiety, suicidal ideation, self-harm, and other risk taking behaviors. Visits with pubertal GN youth, as with any adolescent, should include confidential time alone with the medical provider to discuss any concerns. Youth should be informed that information will be kept confidential, but parents will need to be notified of any safety concerns (such as suicidality or self-harm). As with prepubertal youth, a history related to hair and clothing preferences; distress related to genital anatomy; and the desire to be the other gender should be obtained. A pubertal history and any related symptoms of distress also should be obtained.
DO
• Ask preferred name and pronoun.
• Perform confidential strength and risk assessment.
• Assess for family and social support.
• Refer to appropriate mental health and transgender providers.
DON’T
• Assume names and pronouns.
• Interview patient only with parent in the room.
• Disclose identity without patient consent.
• Dismiss parents as sources of support.
• Refer for reparative therapy.4
Youth who are suspected to have a diagnosis of gender dysphoria should be referred to mental health and medical providers with experience caring for transgender youth. These specialists can work with patients and families, and determine when and if youth are eligible for puberty blocking therapy with GnRH analogues and/or hormone therapy. GnRH analogues, if appropriate, can be prescribed after patients have reached sexual maturity rating stage 2. The rationale for this treatment is to prevent the development of unwanted secondary sex characteristics while giving the youth a chance to continue with psychotherapy and explore their gender identity.5 Hormone therapy, if appropriate, can be prescribed a few years later under the care of a transgender specialist and mental health provider.
Summary
It is normal to experiment with gender roles and expression in childhood. Providing a safe space to do this is important.
Individuals who have a persistent, consistent, and insistent gender-nonconforming identification and who have increased distress with puberty are unlikely to have this subside.
Pediatricians can assess for gender dysphoria and screen for related mood disorders and behaviors in the primary care setting. Appropriate referral to trained professionals is important.
Care should be individualized and focused on the health and safety of the patient.
Resources
For health care professionals
• World Professional Association for Transgender Health: Standards of care on care of transgender patients and provider directory. www.wpath.org• Physicians for Reproductive Health’s adolescent reproductive and sexual health education program (ARSHEP): Best practices for adolescent and reproductive health: Module on caring for transgender adolescent patients. prh.org/teen-reproductive-health/arshep-downloads/
For patients and families
• Family Acceptance Project: familyproject.sfsu.edu/
• Healthychildren.org: Parenting website supported by the American Academy of Pediatrics. Links to articles on gender nonconforming and transgender children; gender identity development in children. www.healthychildren.org
References
1. Caring for Your School Age Child: Ages 5-12 by the American Academy of Pediatrics (New York: Bantam Books, 1995).
2. Dev Psychol. 2008 Jan;44(1):34-45.
3. J Am Acad Child and Adolesc Psychiatry. 2008;47(12):1413-23
4. Caring for Transgender Adolescent Patients. Physicians for Reproductive Health’s Adolescent Reproductive and Sexual Health Education Program (ARSHEP): Best practices for adolescent and reproductive health: prh.org/teen-reproductive-health/arshep-downloads/
5. World Professional Association of Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th Edition (International Journal of Transgenderism. 2011;13:165-232)
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.
Guidance for parents of LGBT youth
Two years ago, a mother of one of my patients asked me for advice. She knew that her daughter identified as lesbian, and she was fully supportive. One day, her daughter wanted to go to a sleepover at a female friend’s house. Her first reaction was to say yes, but then she had second thoughts: If her daughter were straight, and this friend were male, she would not allow her to go because of the potential for sexual activity. When she told her daughter she could not attend the sleepover, her daughter accused her of not letting her go because of her sexual orientation. And now, the dilemma: In her effort to be fair and consistent with her values, the mother is being accused of discrimination. What should she do?
Parents play an irreplaceable role in the life of any teen, especially in the lives of teens that identify as lesbian, gay, bisexual, or transgender (LGBT). But many LGBT youth face serious challenges with their parents. They face the potential of parental rejection of their sexual or gender identity. At the very worst, teens may face homelessness if they come out to homophobic parents.1 Youth whose parents are accepting, nevertheless, are less likely to have mental health problems or engage in substance use.2
As a clinical provider for children and adolescents, caregivers will ask you for advice on how to address parenting challenges. Because LGBT youth are at risk for many adverse health outcomes, and parental support is paramount in preventing them, this is an opportunity for you to help this vulnerable population.
If parents ask you how to be supportive of their LGBT children, here are some recommendations, which are based on an intervention by colleagues at the University of Utah:3
1. Let their affection show. Receiving news that a child is LGBT can be emotionally intense for parents.4 Because of this emotional intensity, parents may react negatively and neglect to show their love for their child, which is what the child is seeking. Parents showing affection is the first step in supporting their LGBT child. Remind parents to tell their child that they love them no matter what.
2. Avoid rejecting behaviors. This is sometimes hard, because some forms of rejection can be quite subtle. Avoid saying anything that may indicate a negative view of LGBT people, even if it is not intended. For example, saying that something is “gay” may seem innocent enough, but it sends the message that being gay is something to be ashamed of.
3. Express their pain away from their child. Evidence shows that minimizing a child’s exposure to parental conflict and stress is associated with better coping with these devastating events.5 Parents should avoid telling their children that news of their sexual orientation or gender identity upsets them, as this is another form of rejecting behavior.
4. Do good before they feel good. Previous studies suggest that changes in behavior can occur even though a person may feel otherwise.6 Negative feelings about a child’s sexual orientation or gender identity can last months or years.7 It’s okay to have these feelings, but showing support such as telling their child how they still love them can ultimately lead to acceptance.
Although it is important for parents to accept their child, it is only half the battle. If you remember Baumrind’s theory on parenting, there are two sides of parenting. The first side involves parents showing their affection, love, and support for their children, which I described earlier. The other side involves managing a child’s behaviors, whether parents create an environment that makes it difficult to engage in behaviors they disapprove of or teach their children how to make the right decision.8 Many LGBT youth engage in risky behaviors because it’s a way of coping in a homophobic environment. The parents’ job is to teach their children healthier coping strategies.
Research on this aspect of parenting in LGBT youth is still at its infancy, and some of it is not reassuring. One important behavior, parental monitoring, which is “a set of correlated parenting behaviors involving attention to and tracking of the child’s whereabouts, activities, and adaptations,”9 can prevent conduct disorders, substance use, and mental health problems in the typical teenager.10 Unfortunately, we don’t find the same results for sexual minorities. One study suggests that parental monitoring may not prevent high-risk sexual behavior for young gay males, even if the parent is aware of the young man’s sexual orientation.11
This doesn’t mean that parental monitoring isn’t helpful. This just means that parenting LGBT youth is different than parenting heterosexual youth. It’s not enough for parents to just accept their child’s sexual orientation. They also must help them make the right decisions taking into consideration the effect of stigma and discrimination on sexual minorities. There are a couple of things you can suggest to your parents to help them raise their LGBT children:
1. Be proactive. Join organizations that support parents of LGBT youth such as Parents, Families, and Friends of Lesbians and Gays (PFLAG). Also, parents must be aware of their children’s behavior. If they are acting depressed, seek help. Having depression or anxiety increases the chances of engaging in risky behaviors, so the earlier parents address this, the better.
2. Make their child know what their views are on high risk-behaviors, such as substance use or having unprotected sex. They need to communicate their expectations clearly. If parents believe that drinking alcohol before the legal age is wrong, they should clearly let their children know that.
3. Make it easier for their child to tell parents what’s going on in their lives. Parents have to gain their children’s trust, be accessible (don’t answer texts while talking to them!), and be an active listener. LGBT youth may not ask parents for advice because they feel that because their parents are straight or cisgender, their life experiences do not apply. Being a member of an organization like PLFAG can be helpful, because parents can ask other parents who have experience raising LGBT youth for advice that works.
4. If parents’ children do something wrong, they should talk to them about how their actions were risky. Children will listen to parents if they view their parenting as legitimate and fair, which can only happen if there is a strong parent-child relationship. Being supportive of a child’s sexual orientation or gender identity is key here. And for the next time, it’s always good to role-play a scenario (for example, what to do if someone tries to make them drink at a party).
Parents of LGBT youth face many challenges. You can help these parents by encouraging them to accept and support their child’s sexual orientation or gender identity and provide parenting strategies relevant for LGBT youth. Most important of all, encourage them to seek support through organizations like PFLAG. With this support, parents can encourage healthy development in LGBT youth.
Resources for parents of LGBT youth
• The Centers for Disease Control and Prevention (CDC) has information on the health of LGBT Youth and advice on parental monitoring in general.
• The Family Acceptance Project is a project researching ways to improve parent-child relationships in LGBT Youth.
• PFLAG is an organization that provides support for families of LGBT youth.
• Lead with Love is a film about how various types of families react to their children coming out to them.
References
1. J Sex Res. 2004 Nov;41(4):329-42.
2. Aust N Z J Psychiatry. 2010 Sep;44(9):774-83.
3. Huebner D. “Leading with Love: Interventions to Support Families of Lesbian, Gay, and Bisexual Adolescents,” The Register Report, Vol. 39. National Register of Health Service Psychologists, Spring 2013.
4. J GLBT Fam Stud. 2014 Jan;10(1-2):36-57.
5. Prof Psychol Res Pr. 2008 Apr;39(2):113-21.
6. “Behaviorism: Classic Studies” (Casper, Wyo: Endeavor Books/Mountain States Litho, 2009).
7. Journal of LGBT Issues in Counseling. 2008;2(2):126-58.
8. Genet Psychol Monogr. 1967;75(1):43-88.
9. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.
10. “Parental Monitoring of Adolescents: Current Perspectives for Researchers and Practitioners” (New York: Columbia University Press, 2010).
11. AIDS Behav. 2014 Aug;18(8):1604-14.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].
Two years ago, a mother of one of my patients asked me for advice. She knew that her daughter identified as lesbian, and she was fully supportive. One day, her daughter wanted to go to a sleepover at a female friend’s house. Her first reaction was to say yes, but then she had second thoughts: If her daughter were straight, and this friend were male, she would not allow her to go because of the potential for sexual activity. When she told her daughter she could not attend the sleepover, her daughter accused her of not letting her go because of her sexual orientation. And now, the dilemma: In her effort to be fair and consistent with her values, the mother is being accused of discrimination. What should she do?
Parents play an irreplaceable role in the life of any teen, especially in the lives of teens that identify as lesbian, gay, bisexual, or transgender (LGBT). But many LGBT youth face serious challenges with their parents. They face the potential of parental rejection of their sexual or gender identity. At the very worst, teens may face homelessness if they come out to homophobic parents.1 Youth whose parents are accepting, nevertheless, are less likely to have mental health problems or engage in substance use.2
As a clinical provider for children and adolescents, caregivers will ask you for advice on how to address parenting challenges. Because LGBT youth are at risk for many adverse health outcomes, and parental support is paramount in preventing them, this is an opportunity for you to help this vulnerable population.
If parents ask you how to be supportive of their LGBT children, here are some recommendations, which are based on an intervention by colleagues at the University of Utah:3
1. Let their affection show. Receiving news that a child is LGBT can be emotionally intense for parents.4 Because of this emotional intensity, parents may react negatively and neglect to show their love for their child, which is what the child is seeking. Parents showing affection is the first step in supporting their LGBT child. Remind parents to tell their child that they love them no matter what.
2. Avoid rejecting behaviors. This is sometimes hard, because some forms of rejection can be quite subtle. Avoid saying anything that may indicate a negative view of LGBT people, even if it is not intended. For example, saying that something is “gay” may seem innocent enough, but it sends the message that being gay is something to be ashamed of.
3. Express their pain away from their child. Evidence shows that minimizing a child’s exposure to parental conflict and stress is associated with better coping with these devastating events.5 Parents should avoid telling their children that news of their sexual orientation or gender identity upsets them, as this is another form of rejecting behavior.
4. Do good before they feel good. Previous studies suggest that changes in behavior can occur even though a person may feel otherwise.6 Negative feelings about a child’s sexual orientation or gender identity can last months or years.7 It’s okay to have these feelings, but showing support such as telling their child how they still love them can ultimately lead to acceptance.
Although it is important for parents to accept their child, it is only half the battle. If you remember Baumrind’s theory on parenting, there are two sides of parenting. The first side involves parents showing their affection, love, and support for their children, which I described earlier. The other side involves managing a child’s behaviors, whether parents create an environment that makes it difficult to engage in behaviors they disapprove of or teach their children how to make the right decision.8 Many LGBT youth engage in risky behaviors because it’s a way of coping in a homophobic environment. The parents’ job is to teach their children healthier coping strategies.
Research on this aspect of parenting in LGBT youth is still at its infancy, and some of it is not reassuring. One important behavior, parental monitoring, which is “a set of correlated parenting behaviors involving attention to and tracking of the child’s whereabouts, activities, and adaptations,”9 can prevent conduct disorders, substance use, and mental health problems in the typical teenager.10 Unfortunately, we don’t find the same results for sexual minorities. One study suggests that parental monitoring may not prevent high-risk sexual behavior for young gay males, even if the parent is aware of the young man’s sexual orientation.11
This doesn’t mean that parental monitoring isn’t helpful. This just means that parenting LGBT youth is different than parenting heterosexual youth. It’s not enough for parents to just accept their child’s sexual orientation. They also must help them make the right decisions taking into consideration the effect of stigma and discrimination on sexual minorities. There are a couple of things you can suggest to your parents to help them raise their LGBT children:
1. Be proactive. Join organizations that support parents of LGBT youth such as Parents, Families, and Friends of Lesbians and Gays (PFLAG). Also, parents must be aware of their children’s behavior. If they are acting depressed, seek help. Having depression or anxiety increases the chances of engaging in risky behaviors, so the earlier parents address this, the better.
2. Make their child know what their views are on high risk-behaviors, such as substance use or having unprotected sex. They need to communicate their expectations clearly. If parents believe that drinking alcohol before the legal age is wrong, they should clearly let their children know that.
3. Make it easier for their child to tell parents what’s going on in their lives. Parents have to gain their children’s trust, be accessible (don’t answer texts while talking to them!), and be an active listener. LGBT youth may not ask parents for advice because they feel that because their parents are straight or cisgender, their life experiences do not apply. Being a member of an organization like PLFAG can be helpful, because parents can ask other parents who have experience raising LGBT youth for advice that works.
4. If parents’ children do something wrong, they should talk to them about how their actions were risky. Children will listen to parents if they view their parenting as legitimate and fair, which can only happen if there is a strong parent-child relationship. Being supportive of a child’s sexual orientation or gender identity is key here. And for the next time, it’s always good to role-play a scenario (for example, what to do if someone tries to make them drink at a party).
Parents of LGBT youth face many challenges. You can help these parents by encouraging them to accept and support their child’s sexual orientation or gender identity and provide parenting strategies relevant for LGBT youth. Most important of all, encourage them to seek support through organizations like PFLAG. With this support, parents can encourage healthy development in LGBT youth.
Resources for parents of LGBT youth
• The Centers for Disease Control and Prevention (CDC) has information on the health of LGBT Youth and advice on parental monitoring in general.
• The Family Acceptance Project is a project researching ways to improve parent-child relationships in LGBT Youth.
• PFLAG is an organization that provides support for families of LGBT youth.
• Lead with Love is a film about how various types of families react to their children coming out to them.
References
1. J Sex Res. 2004 Nov;41(4):329-42.
2. Aust N Z J Psychiatry. 2010 Sep;44(9):774-83.
3. Huebner D. “Leading with Love: Interventions to Support Families of Lesbian, Gay, and Bisexual Adolescents,” The Register Report, Vol. 39. National Register of Health Service Psychologists, Spring 2013.
4. J GLBT Fam Stud. 2014 Jan;10(1-2):36-57.
5. Prof Psychol Res Pr. 2008 Apr;39(2):113-21.
6. “Behaviorism: Classic Studies” (Casper, Wyo: Endeavor Books/Mountain States Litho, 2009).
7. Journal of LGBT Issues in Counseling. 2008;2(2):126-58.
8. Genet Psychol Monogr. 1967;75(1):43-88.
9. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.
10. “Parental Monitoring of Adolescents: Current Perspectives for Researchers and Practitioners” (New York: Columbia University Press, 2010).
11. AIDS Behav. 2014 Aug;18(8):1604-14.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].
Two years ago, a mother of one of my patients asked me for advice. She knew that her daughter identified as lesbian, and she was fully supportive. One day, her daughter wanted to go to a sleepover at a female friend’s house. Her first reaction was to say yes, but then she had second thoughts: If her daughter were straight, and this friend were male, she would not allow her to go because of the potential for sexual activity. When she told her daughter she could not attend the sleepover, her daughter accused her of not letting her go because of her sexual orientation. And now, the dilemma: In her effort to be fair and consistent with her values, the mother is being accused of discrimination. What should she do?
Parents play an irreplaceable role in the life of any teen, especially in the lives of teens that identify as lesbian, gay, bisexual, or transgender (LGBT). But many LGBT youth face serious challenges with their parents. They face the potential of parental rejection of their sexual or gender identity. At the very worst, teens may face homelessness if they come out to homophobic parents.1 Youth whose parents are accepting, nevertheless, are less likely to have mental health problems or engage in substance use.2
As a clinical provider for children and adolescents, caregivers will ask you for advice on how to address parenting challenges. Because LGBT youth are at risk for many adverse health outcomes, and parental support is paramount in preventing them, this is an opportunity for you to help this vulnerable population.
If parents ask you how to be supportive of their LGBT children, here are some recommendations, which are based on an intervention by colleagues at the University of Utah:3
1. Let their affection show. Receiving news that a child is LGBT can be emotionally intense for parents.4 Because of this emotional intensity, parents may react negatively and neglect to show their love for their child, which is what the child is seeking. Parents showing affection is the first step in supporting their LGBT child. Remind parents to tell their child that they love them no matter what.
2. Avoid rejecting behaviors. This is sometimes hard, because some forms of rejection can be quite subtle. Avoid saying anything that may indicate a negative view of LGBT people, even if it is not intended. For example, saying that something is “gay” may seem innocent enough, but it sends the message that being gay is something to be ashamed of.
3. Express their pain away from their child. Evidence shows that minimizing a child’s exposure to parental conflict and stress is associated with better coping with these devastating events.5 Parents should avoid telling their children that news of their sexual orientation or gender identity upsets them, as this is another form of rejecting behavior.
4. Do good before they feel good. Previous studies suggest that changes in behavior can occur even though a person may feel otherwise.6 Negative feelings about a child’s sexual orientation or gender identity can last months or years.7 It’s okay to have these feelings, but showing support such as telling their child how they still love them can ultimately lead to acceptance.
Although it is important for parents to accept their child, it is only half the battle. If you remember Baumrind’s theory on parenting, there are two sides of parenting. The first side involves parents showing their affection, love, and support for their children, which I described earlier. The other side involves managing a child’s behaviors, whether parents create an environment that makes it difficult to engage in behaviors they disapprove of or teach their children how to make the right decision.8 Many LGBT youth engage in risky behaviors because it’s a way of coping in a homophobic environment. The parents’ job is to teach their children healthier coping strategies.
Research on this aspect of parenting in LGBT youth is still at its infancy, and some of it is not reassuring. One important behavior, parental monitoring, which is “a set of correlated parenting behaviors involving attention to and tracking of the child’s whereabouts, activities, and adaptations,”9 can prevent conduct disorders, substance use, and mental health problems in the typical teenager.10 Unfortunately, we don’t find the same results for sexual minorities. One study suggests that parental monitoring may not prevent high-risk sexual behavior for young gay males, even if the parent is aware of the young man’s sexual orientation.11
This doesn’t mean that parental monitoring isn’t helpful. This just means that parenting LGBT youth is different than parenting heterosexual youth. It’s not enough for parents to just accept their child’s sexual orientation. They also must help them make the right decisions taking into consideration the effect of stigma and discrimination on sexual minorities. There are a couple of things you can suggest to your parents to help them raise their LGBT children:
1. Be proactive. Join organizations that support parents of LGBT youth such as Parents, Families, and Friends of Lesbians and Gays (PFLAG). Also, parents must be aware of their children’s behavior. If they are acting depressed, seek help. Having depression or anxiety increases the chances of engaging in risky behaviors, so the earlier parents address this, the better.
2. Make their child know what their views are on high risk-behaviors, such as substance use or having unprotected sex. They need to communicate their expectations clearly. If parents believe that drinking alcohol before the legal age is wrong, they should clearly let their children know that.
3. Make it easier for their child to tell parents what’s going on in their lives. Parents have to gain their children’s trust, be accessible (don’t answer texts while talking to them!), and be an active listener. LGBT youth may not ask parents for advice because they feel that because their parents are straight or cisgender, their life experiences do not apply. Being a member of an organization like PLFAG can be helpful, because parents can ask other parents who have experience raising LGBT youth for advice that works.
4. If parents’ children do something wrong, they should talk to them about how their actions were risky. Children will listen to parents if they view their parenting as legitimate and fair, which can only happen if there is a strong parent-child relationship. Being supportive of a child’s sexual orientation or gender identity is key here. And for the next time, it’s always good to role-play a scenario (for example, what to do if someone tries to make them drink at a party).
Parents of LGBT youth face many challenges. You can help these parents by encouraging them to accept and support their child’s sexual orientation or gender identity and provide parenting strategies relevant for LGBT youth. Most important of all, encourage them to seek support through organizations like PFLAG. With this support, parents can encourage healthy development in LGBT youth.
Resources for parents of LGBT youth
• The Centers for Disease Control and Prevention (CDC) has information on the health of LGBT Youth and advice on parental monitoring in general.
• The Family Acceptance Project is a project researching ways to improve parent-child relationships in LGBT Youth.
• PFLAG is an organization that provides support for families of LGBT youth.
• Lead with Love is a film about how various types of families react to their children coming out to them.
References
1. J Sex Res. 2004 Nov;41(4):329-42.
2. Aust N Z J Psychiatry. 2010 Sep;44(9):774-83.
3. Huebner D. “Leading with Love: Interventions to Support Families of Lesbian, Gay, and Bisexual Adolescents,” The Register Report, Vol. 39. National Register of Health Service Psychologists, Spring 2013.
4. J GLBT Fam Stud. 2014 Jan;10(1-2):36-57.
5. Prof Psychol Res Pr. 2008 Apr;39(2):113-21.
6. “Behaviorism: Classic Studies” (Casper, Wyo: Endeavor Books/Mountain States Litho, 2009).
7. Journal of LGBT Issues in Counseling. 2008;2(2):126-58.
8. Genet Psychol Monogr. 1967;75(1):43-88.
9. Clin Child Fam Psychol Rev. 1998 Mar;1(1):61-75.
10. “Parental Monitoring of Adolescents: Current Perspectives for Researchers and Practitioners” (New York: Columbia University Press, 2010).
11. AIDS Behav. 2014 Aug;18(8):1604-14.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].
Risks of tobacco use in the LGBT community
Tobacco addiction and smoke exposure are among the leading causes of preventable and premature death and disability in the United States and elsewhere in the world. The landmark 2012 Surgeon General’s report, Preventing Tobacco Use Among Youth and Young Adults, stated, “The vast majority of Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood.” All youth are at risk for experimenting and using “standard” tobacco products, as well as relatively new merchandise such as e-cigarettes, hookas, bidis (small, hand-rolled cigarettes), and little cigars (Pediatrics. 2013 Aug 5;132:e578-86). In a 2015 article, data show more than twice as many youth use two or more types of tobacco products than use cigarettes alone (Pediatrics. 2015 March;135:409-15).
In a 2015 American Academy of Pediatrics policy statement, the academy stated that all children, adolescents, and young adults must be safeguarded from using all of the various tobacco products (Pediatrics. 2015 Oct 26. doi: 10.1542/peds.2015-3108). Therefore, a working knowledge of the various types of products is essential when speaking with youth on this subject.
The AAP recommended that all children and youth, without exception, must be considered to be at risk for using tobacco products. Therefore, all youth should be counseled, as the AAP made no exceptions with regard to race, national origin, ethnic group, socioeconomic status, or membership in the LGBT community.
Tobacco use by sexual identity
Much more needs to be known with regard to tobacco use for all children, youth, and young adults. National surveillance data are needed for the LGBT community, whose members have unique health care needs. A 2013 article demonstrated disparities in the use of tobacco products in young adults in the LGBT community (Nicotine Tob Res. 2013;15[11]:1822-31).
This study used data from the American Legacy Foundation’s Young Adult Study. The survey compared the use of tobacco by the LGBT community versus the heterosexual community during the previous 30-day period. The prevalence of use of tobacco products for young adults who self-identified as sexual minorities was statistically higher than for their heterosexual counterparts. For example, current use of tobacco products was 22% in heterosexual young adults, compared with 35% in young adults who identified as homosexual and 31% in young adults who identified as bisexual.
However, this same publication stated that there are very few studies on this subject, including why there are these disparities. This information is important to know so better approaches can be developed to address these issues. In addition, health care providers must address the issue of tobacco use by youth and young adults, and develop specific approaches that can specifically target at-risk populations that are culturally competent. The authors concluded that it remains unclear why the tobacco use rate among the LGBT community is significantly higher than in their peers who are heterosexual. Risk factors that have been posited include social stigma, the role of bars in this community, and alcohol and drug use. Also, social acceptance issues, inclusion issues, alienation and depression, and marketing by tobacco manufacturers may be risk factors.
Much work remains to be done to address these risk factors and, therefore, the use of tobacco and similar drugs. The 2012 surgeon general’s report emphasized that health care providers of young people must address these issues directly and consistently with their patients.
Practical next steps for your practice
One approach to addressing tobacco use with your patients is to implement the “5 A’s”:
1. Anticipate/Ask. Ask young people if they or their friends are interested in tobacco products and/or if they use tobacco products of any type. Do this at every visit.
2. Advise. In clear, strong, personalized language, urge the tobacco user to quit.
3. Assess. Assess the willingness of the tobacco user to quit, and urge the youth to quit smoking.
4. Assist. For the youth willing to quit, use counseling yourself and/or refer for counseling to individuals with expertise in tobacco cessation or support groups, and consider pharmacotherapy if necessary.
5. Arrange. Schedule a follow-up contact in person within the first week and then on a regularly scheduled basis.
The 5 A’s have been recognized by the Agency for Healthcare Research and Quality as an evidence-based practice for both adult and pediatric patients. In a 2014 article, Dr. Jonathan Klein reported on a study of youth who had seen a clinician for a preventive visit within the past year. However, the youth also reported that the rate of their receiving counseling on tobacco use was relatively low (Pediatrics. 2014 Sep;134[3]:600-1) Most recently, Howard University completed a project funded by the District of Columbia Department of Health to develop and teach a curriculum for medical and nursing students, residents, and physician and nursing staff on this important issue. The youth whom we interviewed in developing the curriculum reported that they had never received counseling by health professionals during their preventive health care visits. This important issue needs to be addressed because it truly is a key to future health for our children and youth.
Dr. Tierney is a Washington-based pediatrician who is a member of the Institute for Public Health Innovation and the D.C. Primary Care Association Medicaid Financing Task Force on Medicaid payment for community health workers. She also works with Howard University Hospital’s Cancer Center on tobacco use avoidance and/or cessation by African American youth. She is on the board of Whitman-Walker Health to advise on Medicaid payment and sits on the quality assurance committee.
Tobacco addiction and smoke exposure are among the leading causes of preventable and premature death and disability in the United States and elsewhere in the world. The landmark 2012 Surgeon General’s report, Preventing Tobacco Use Among Youth and Young Adults, stated, “The vast majority of Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood.” All youth are at risk for experimenting and using “standard” tobacco products, as well as relatively new merchandise such as e-cigarettes, hookas, bidis (small, hand-rolled cigarettes), and little cigars (Pediatrics. 2013 Aug 5;132:e578-86). In a 2015 article, data show more than twice as many youth use two or more types of tobacco products than use cigarettes alone (Pediatrics. 2015 March;135:409-15).
In a 2015 American Academy of Pediatrics policy statement, the academy stated that all children, adolescents, and young adults must be safeguarded from using all of the various tobacco products (Pediatrics. 2015 Oct 26. doi: 10.1542/peds.2015-3108). Therefore, a working knowledge of the various types of products is essential when speaking with youth on this subject.
The AAP recommended that all children and youth, without exception, must be considered to be at risk for using tobacco products. Therefore, all youth should be counseled, as the AAP made no exceptions with regard to race, national origin, ethnic group, socioeconomic status, or membership in the LGBT community.
Tobacco use by sexual identity
Much more needs to be known with regard to tobacco use for all children, youth, and young adults. National surveillance data are needed for the LGBT community, whose members have unique health care needs. A 2013 article demonstrated disparities in the use of tobacco products in young adults in the LGBT community (Nicotine Tob Res. 2013;15[11]:1822-31).
This study used data from the American Legacy Foundation’s Young Adult Study. The survey compared the use of tobacco by the LGBT community versus the heterosexual community during the previous 30-day period. The prevalence of use of tobacco products for young adults who self-identified as sexual minorities was statistically higher than for their heterosexual counterparts. For example, current use of tobacco products was 22% in heterosexual young adults, compared with 35% in young adults who identified as homosexual and 31% in young adults who identified as bisexual.
However, this same publication stated that there are very few studies on this subject, including why there are these disparities. This information is important to know so better approaches can be developed to address these issues. In addition, health care providers must address the issue of tobacco use by youth and young adults, and develop specific approaches that can specifically target at-risk populations that are culturally competent. The authors concluded that it remains unclear why the tobacco use rate among the LGBT community is significantly higher than in their peers who are heterosexual. Risk factors that have been posited include social stigma, the role of bars in this community, and alcohol and drug use. Also, social acceptance issues, inclusion issues, alienation and depression, and marketing by tobacco manufacturers may be risk factors.
Much work remains to be done to address these risk factors and, therefore, the use of tobacco and similar drugs. The 2012 surgeon general’s report emphasized that health care providers of young people must address these issues directly and consistently with their patients.
Practical next steps for your practice
One approach to addressing tobacco use with your patients is to implement the “5 A’s”:
1. Anticipate/Ask. Ask young people if they or their friends are interested in tobacco products and/or if they use tobacco products of any type. Do this at every visit.
2. Advise. In clear, strong, personalized language, urge the tobacco user to quit.
3. Assess. Assess the willingness of the tobacco user to quit, and urge the youth to quit smoking.
4. Assist. For the youth willing to quit, use counseling yourself and/or refer for counseling to individuals with expertise in tobacco cessation or support groups, and consider pharmacotherapy if necessary.
5. Arrange. Schedule a follow-up contact in person within the first week and then on a regularly scheduled basis.
The 5 A’s have been recognized by the Agency for Healthcare Research and Quality as an evidence-based practice for both adult and pediatric patients. In a 2014 article, Dr. Jonathan Klein reported on a study of youth who had seen a clinician for a preventive visit within the past year. However, the youth also reported that the rate of their receiving counseling on tobacco use was relatively low (Pediatrics. 2014 Sep;134[3]:600-1) Most recently, Howard University completed a project funded by the District of Columbia Department of Health to develop and teach a curriculum for medical and nursing students, residents, and physician and nursing staff on this important issue. The youth whom we interviewed in developing the curriculum reported that they had never received counseling by health professionals during their preventive health care visits. This important issue needs to be addressed because it truly is a key to future health for our children and youth.
Dr. Tierney is a Washington-based pediatrician who is a member of the Institute for Public Health Innovation and the D.C. Primary Care Association Medicaid Financing Task Force on Medicaid payment for community health workers. She also works with Howard University Hospital’s Cancer Center on tobacco use avoidance and/or cessation by African American youth. She is on the board of Whitman-Walker Health to advise on Medicaid payment and sits on the quality assurance committee.
Tobacco addiction and smoke exposure are among the leading causes of preventable and premature death and disability in the United States and elsewhere in the world. The landmark 2012 Surgeon General’s report, Preventing Tobacco Use Among Youth and Young Adults, stated, “The vast majority of Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood.” All youth are at risk for experimenting and using “standard” tobacco products, as well as relatively new merchandise such as e-cigarettes, hookas, bidis (small, hand-rolled cigarettes), and little cigars (Pediatrics. 2013 Aug 5;132:e578-86). In a 2015 article, data show more than twice as many youth use two or more types of tobacco products than use cigarettes alone (Pediatrics. 2015 March;135:409-15).
In a 2015 American Academy of Pediatrics policy statement, the academy stated that all children, adolescents, and young adults must be safeguarded from using all of the various tobacco products (Pediatrics. 2015 Oct 26. doi: 10.1542/peds.2015-3108). Therefore, a working knowledge of the various types of products is essential when speaking with youth on this subject.
The AAP recommended that all children and youth, without exception, must be considered to be at risk for using tobacco products. Therefore, all youth should be counseled, as the AAP made no exceptions with regard to race, national origin, ethnic group, socioeconomic status, or membership in the LGBT community.
Tobacco use by sexual identity
Much more needs to be known with regard to tobacco use for all children, youth, and young adults. National surveillance data are needed for the LGBT community, whose members have unique health care needs. A 2013 article demonstrated disparities in the use of tobacco products in young adults in the LGBT community (Nicotine Tob Res. 2013;15[11]:1822-31).
This study used data from the American Legacy Foundation’s Young Adult Study. The survey compared the use of tobacco by the LGBT community versus the heterosexual community during the previous 30-day period. The prevalence of use of tobacco products for young adults who self-identified as sexual minorities was statistically higher than for their heterosexual counterparts. For example, current use of tobacco products was 22% in heterosexual young adults, compared with 35% in young adults who identified as homosexual and 31% in young adults who identified as bisexual.
However, this same publication stated that there are very few studies on this subject, including why there are these disparities. This information is important to know so better approaches can be developed to address these issues. In addition, health care providers must address the issue of tobacco use by youth and young adults, and develop specific approaches that can specifically target at-risk populations that are culturally competent. The authors concluded that it remains unclear why the tobacco use rate among the LGBT community is significantly higher than in their peers who are heterosexual. Risk factors that have been posited include social stigma, the role of bars in this community, and alcohol and drug use. Also, social acceptance issues, inclusion issues, alienation and depression, and marketing by tobacco manufacturers may be risk factors.
Much work remains to be done to address these risk factors and, therefore, the use of tobacco and similar drugs. The 2012 surgeon general’s report emphasized that health care providers of young people must address these issues directly and consistently with their patients.
Practical next steps for your practice
One approach to addressing tobacco use with your patients is to implement the “5 A’s”:
1. Anticipate/Ask. Ask young people if they or their friends are interested in tobacco products and/or if they use tobacco products of any type. Do this at every visit.
2. Advise. In clear, strong, personalized language, urge the tobacco user to quit.
3. Assess. Assess the willingness of the tobacco user to quit, and urge the youth to quit smoking.
4. Assist. For the youth willing to quit, use counseling yourself and/or refer for counseling to individuals with expertise in tobacco cessation or support groups, and consider pharmacotherapy if necessary.
5. Arrange. Schedule a follow-up contact in person within the first week and then on a regularly scheduled basis.
The 5 A’s have been recognized by the Agency for Healthcare Research and Quality as an evidence-based practice for both adult and pediatric patients. In a 2014 article, Dr. Jonathan Klein reported on a study of youth who had seen a clinician for a preventive visit within the past year. However, the youth also reported that the rate of their receiving counseling on tobacco use was relatively low (Pediatrics. 2014 Sep;134[3]:600-1) Most recently, Howard University completed a project funded by the District of Columbia Department of Health to develop and teach a curriculum for medical and nursing students, residents, and physician and nursing staff on this important issue. The youth whom we interviewed in developing the curriculum reported that they had never received counseling by health professionals during their preventive health care visits. This important issue needs to be addressed because it truly is a key to future health for our children and youth.
Dr. Tierney is a Washington-based pediatrician who is a member of the Institute for Public Health Innovation and the D.C. Primary Care Association Medicaid Financing Task Force on Medicaid payment for community health workers. She also works with Howard University Hospital’s Cancer Center on tobacco use avoidance and/or cessation by African American youth. She is on the board of Whitman-Walker Health to advise on Medicaid payment and sits on the quality assurance committee.
Caring for gender-nonconforming youth
As a member of a multidisciplinary clinic that cares for gender-nonconforming (GN) youth, I frequently field questions from providers about how to handle gender identity concerns in the primary care setting. The specific health care needs of these youth matter as GN youth are at increased risk of self-harm, suicide attempts, mood disorders, eating disorders, substance use, and low school performance.1, 2 These increased risks appear to be related to the rejection and stigma associated with gender nonconformity that can extend to the health care setting.
More than 50% of transgender adults report experiences of discrimination in health care.3 The literature suggests that creating a supportive and affirming environment for GN youth may decrease these risks. If we can do just that during their health care visits, we can make a positive impact on our patients.
Terminology
A review of terminology and clarification of the difference between biologic sex, gender identity, gender expression, and sexual orientation are necessary before discussing the care of GN youth. Biologic sex is typically assigned at birth and is determined by a person’s chromosomes, hormones, and anatomy. Sex most commonly is female or male. For a minority of the population, there may be disorders or differences of sex development in which the development of chromosomal, gonadal, or anatomic sex is atypical. Examples of these conditions are congenital adrenal hyperplasia and androgen insensitivity syndrome. Gender includes the behavioral, cultural, and psychological characteristics associated with femaleness or maleness.2 Gender identity is a person’s innate sense of feeling male, female, or somewhere in between. Individuals who have a gender identity that is congruent with their assigned sex are referred to as cisgender; those who have a gender identity that does not align with their birth sex are often referred to as transgender. Gender expression is how people choose to present themselves to the world. A person’s gender may or may not be consistent with his/her internal gender identity. For example, an individual may be female biologically (XX chromosomes, with a uterus, ovaries, and vagina) and self-identify as female, but express herself in a masculine way by having her hair cut short and wearing more masculine clothing.
Gender dysphoria occurs when an individual experiences psychological distress caused by the incongruence between his/her biologic sex and his/her internal gender identity, and this mismatch leads to clinically significant distress or impairment in daily functioning. Gender dysphoria is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It has replaced the earlier diagnosis of gender identity disorder in the DSM-IV. The new diagnosis focuses on the distress related to an incongruence between gender identity and biologic sex and does not label it as pathologic. Gender-nonconforming individuals do not follow other people’s ideas or stereotypes about how they should look or act based on the sex they were assigned at birth. It is important to note that an individual’s gender identity is separate from sexual orientation. Sexual orientation describes an individual’s pattern of sexual and physical attraction. An individual may be attracted to members of the same sex (homosexual, lesbian, gay), opposite sex (heterosexual), or both sexes (bisexual). Increasingly youth are using a variety of terms to describe their gender (for example, genderqueer, asexual, gender fluid) and sexual orientation (for example, pansexual, asexual). These terms may have different meanings for different youth, and it is important to respectfully ask and clarify what these terms mean to each individual patient.
Trajectory of gender identity
Experimenting with gender expression and gender roles is a normal part of childhood. The majority of young children with nonconforming gender identification will not persist with this identification through adolescence. Some of these children will go on to have a nonheterosexual sexual orientation when they are older. While it can be difficult to predict the trajectory of cross-gender identification in early childhood, those with a persistent, insistent, and consistent cross-gender identification in childhood are more likely to experience gender dysphoria and continue with a transgender identity into adulthood. Adolescence is a particularly difficult time for GN youth. The development of secondary sex characteristics that are not consistent with an individual’s identified gender, in addition to the psychosocial challenges of adolescent development, can lead to increased suicidal thoughts, self-harm behaviors, anxiety, isolation, and risk-taking behaviors. Gender dysphoria that increases with the onset of puberty rarely subsides with time.
Approach to GN patients in practice
Research is ongoing related to best practices for the care of GN youth. Clinical guidelines and standards of care have been published and endorsed by organizations including the Endocrine Society, Pediatric Endocrine Society, World Professional Association for Transgender Health, and the American Academy of Pediatrics. My recommendations for the care of GN youth are based on these guidelines.
Primary care providers are often the first place families turn when a child experiences gender identity concerns. Primary care providers can play an important role in providing a safe nonjudgmental environment for patients and families to discuss their concerns, and connecting patients and families to appropriate resources. Providers should first work to educate themselves and their staff about issues affecting GN youth and learn to provide culturally competent care to these youth. Asking youth their preferred names and preferred pronouns (for example, “he/him/his,” “she/her/hers,” “they/them/their,” or something else), documenting this in the medical record, and training clinic staff to use preferred names and pronouns creates an environment that validates, supports, and respects these youth.
It is important to ask all adolescents if they have questions or concerns about their gender identity, in addition to asking questions about sexual identity. It is important when asking these questions to avoid assumptions about an individual’s gender identity based on his or her gender expression. Providers also should familiarize themselves with local referral resources for these youth. As mentioned earlier, GN youth are at high risk for mental health complications including suicide, self-harm, and mood disorders. When referring patients for mental health services, you should be familiar with providers who have expertise in issues of gender identity. A recent report by the Substance Abuse and Mental Health Services Administration states that variations in gender identity are normal, and conversion therapies or other efforts to change gender identity are not effective, are harmful, and are not appropriate therapeutic practices.4
As increasing numbers of youth are identifying as transgender or gender nonconforming, the number of clinics that can coordinate with local providers to provide multidisciplinary care for GN patients is growing.
Resources for health care professionals
• National LGBT Health Education Center, the Fenway Institute. At its website, learning modules, webinars, and other educational resources are available for health care organizations.
• World Professional Association of Transgender Health. This website provides standards of care for transgender patients and a provider directory.
• The Genderbread Person. This website has a helpful infographic illustrating differences between biologic sex, gender identity, gender expression, and sexual orientation, which can be useful for education with patients, families, and trainees.
• Center of Excellence for Transgender Health. This organization works to increase access to comprehensive, effective, and affirming health care services for trans communities.
Resources for patients and families
• The Trevor Project. This website provides crisis intervention and suicide prevention services.
• National Center for Transgender Equality. This advocacy organization works to promote policy change to advance transgender equality.
• Family Acceptance Project. This research, intervention, education, and policy initiative works to prevent health and mental health risks for lesbian, gay, bisexual, and transgender children and youth, including suicide, homelessness, and HIV – in the context of their families, cultures, and faith communities.
References
1. Pediatrics. 2012 Mar;129(3):418-25.
2. Pediatrics. 2014 Dec;134(6):1184-92.
3. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV, Lambda Legal, 2010. Available at www.lambdalegal.org/health-care-report.
4. Substance Abuse and Mental Health Services Administration. Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth. HHS Publication No. (SMA) 15-4928. October 2015. Available at http://store.samhsa.gov/shin/content//SMA15-4928/SMA15-4928.pdf.
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.
As a member of a multidisciplinary clinic that cares for gender-nonconforming (GN) youth, I frequently field questions from providers about how to handle gender identity concerns in the primary care setting. The specific health care needs of these youth matter as GN youth are at increased risk of self-harm, suicide attempts, mood disorders, eating disorders, substance use, and low school performance.1, 2 These increased risks appear to be related to the rejection and stigma associated with gender nonconformity that can extend to the health care setting.
More than 50% of transgender adults report experiences of discrimination in health care.3 The literature suggests that creating a supportive and affirming environment for GN youth may decrease these risks. If we can do just that during their health care visits, we can make a positive impact on our patients.
Terminology
A review of terminology and clarification of the difference between biologic sex, gender identity, gender expression, and sexual orientation are necessary before discussing the care of GN youth. Biologic sex is typically assigned at birth and is determined by a person’s chromosomes, hormones, and anatomy. Sex most commonly is female or male. For a minority of the population, there may be disorders or differences of sex development in which the development of chromosomal, gonadal, or anatomic sex is atypical. Examples of these conditions are congenital adrenal hyperplasia and androgen insensitivity syndrome. Gender includes the behavioral, cultural, and psychological characteristics associated with femaleness or maleness.2 Gender identity is a person’s innate sense of feeling male, female, or somewhere in between. Individuals who have a gender identity that is congruent with their assigned sex are referred to as cisgender; those who have a gender identity that does not align with their birth sex are often referred to as transgender. Gender expression is how people choose to present themselves to the world. A person’s gender may or may not be consistent with his/her internal gender identity. For example, an individual may be female biologically (XX chromosomes, with a uterus, ovaries, and vagina) and self-identify as female, but express herself in a masculine way by having her hair cut short and wearing more masculine clothing.
Gender dysphoria occurs when an individual experiences psychological distress caused by the incongruence between his/her biologic sex and his/her internal gender identity, and this mismatch leads to clinically significant distress or impairment in daily functioning. Gender dysphoria is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It has replaced the earlier diagnosis of gender identity disorder in the DSM-IV. The new diagnosis focuses on the distress related to an incongruence between gender identity and biologic sex and does not label it as pathologic. Gender-nonconforming individuals do not follow other people’s ideas or stereotypes about how they should look or act based on the sex they were assigned at birth. It is important to note that an individual’s gender identity is separate from sexual orientation. Sexual orientation describes an individual’s pattern of sexual and physical attraction. An individual may be attracted to members of the same sex (homosexual, lesbian, gay), opposite sex (heterosexual), or both sexes (bisexual). Increasingly youth are using a variety of terms to describe their gender (for example, genderqueer, asexual, gender fluid) and sexual orientation (for example, pansexual, asexual). These terms may have different meanings for different youth, and it is important to respectfully ask and clarify what these terms mean to each individual patient.
Trajectory of gender identity
Experimenting with gender expression and gender roles is a normal part of childhood. The majority of young children with nonconforming gender identification will not persist with this identification through adolescence. Some of these children will go on to have a nonheterosexual sexual orientation when they are older. While it can be difficult to predict the trajectory of cross-gender identification in early childhood, those with a persistent, insistent, and consistent cross-gender identification in childhood are more likely to experience gender dysphoria and continue with a transgender identity into adulthood. Adolescence is a particularly difficult time for GN youth. The development of secondary sex characteristics that are not consistent with an individual’s identified gender, in addition to the psychosocial challenges of adolescent development, can lead to increased suicidal thoughts, self-harm behaviors, anxiety, isolation, and risk-taking behaviors. Gender dysphoria that increases with the onset of puberty rarely subsides with time.
Approach to GN patients in practice
Research is ongoing related to best practices for the care of GN youth. Clinical guidelines and standards of care have been published and endorsed by organizations including the Endocrine Society, Pediatric Endocrine Society, World Professional Association for Transgender Health, and the American Academy of Pediatrics. My recommendations for the care of GN youth are based on these guidelines.
Primary care providers are often the first place families turn when a child experiences gender identity concerns. Primary care providers can play an important role in providing a safe nonjudgmental environment for patients and families to discuss their concerns, and connecting patients and families to appropriate resources. Providers should first work to educate themselves and their staff about issues affecting GN youth and learn to provide culturally competent care to these youth. Asking youth their preferred names and preferred pronouns (for example, “he/him/his,” “she/her/hers,” “they/them/their,” or something else), documenting this in the medical record, and training clinic staff to use preferred names and pronouns creates an environment that validates, supports, and respects these youth.
It is important to ask all adolescents if they have questions or concerns about their gender identity, in addition to asking questions about sexual identity. It is important when asking these questions to avoid assumptions about an individual’s gender identity based on his or her gender expression. Providers also should familiarize themselves with local referral resources for these youth. As mentioned earlier, GN youth are at high risk for mental health complications including suicide, self-harm, and mood disorders. When referring patients for mental health services, you should be familiar with providers who have expertise in issues of gender identity. A recent report by the Substance Abuse and Mental Health Services Administration states that variations in gender identity are normal, and conversion therapies or other efforts to change gender identity are not effective, are harmful, and are not appropriate therapeutic practices.4
As increasing numbers of youth are identifying as transgender or gender nonconforming, the number of clinics that can coordinate with local providers to provide multidisciplinary care for GN patients is growing.
Resources for health care professionals
• National LGBT Health Education Center, the Fenway Institute. At its website, learning modules, webinars, and other educational resources are available for health care organizations.
• World Professional Association of Transgender Health. This website provides standards of care for transgender patients and a provider directory.
• The Genderbread Person. This website has a helpful infographic illustrating differences between biologic sex, gender identity, gender expression, and sexual orientation, which can be useful for education with patients, families, and trainees.
• Center of Excellence for Transgender Health. This organization works to increase access to comprehensive, effective, and affirming health care services for trans communities.
Resources for patients and families
• The Trevor Project. This website provides crisis intervention and suicide prevention services.
• National Center for Transgender Equality. This advocacy organization works to promote policy change to advance transgender equality.
• Family Acceptance Project. This research, intervention, education, and policy initiative works to prevent health and mental health risks for lesbian, gay, bisexual, and transgender children and youth, including suicide, homelessness, and HIV – in the context of their families, cultures, and faith communities.
References
1. Pediatrics. 2012 Mar;129(3):418-25.
2. Pediatrics. 2014 Dec;134(6):1184-92.
3. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV, Lambda Legal, 2010. Available at www.lambdalegal.org/health-care-report.
4. Substance Abuse and Mental Health Services Administration. Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth. HHS Publication No. (SMA) 15-4928. October 2015. Available at http://store.samhsa.gov/shin/content//SMA15-4928/SMA15-4928.pdf.
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.
As a member of a multidisciplinary clinic that cares for gender-nonconforming (GN) youth, I frequently field questions from providers about how to handle gender identity concerns in the primary care setting. The specific health care needs of these youth matter as GN youth are at increased risk of self-harm, suicide attempts, mood disorders, eating disorders, substance use, and low school performance.1, 2 These increased risks appear to be related to the rejection and stigma associated with gender nonconformity that can extend to the health care setting.
More than 50% of transgender adults report experiences of discrimination in health care.3 The literature suggests that creating a supportive and affirming environment for GN youth may decrease these risks. If we can do just that during their health care visits, we can make a positive impact on our patients.
Terminology
A review of terminology and clarification of the difference between biologic sex, gender identity, gender expression, and sexual orientation are necessary before discussing the care of GN youth. Biologic sex is typically assigned at birth and is determined by a person’s chromosomes, hormones, and anatomy. Sex most commonly is female or male. For a minority of the population, there may be disorders or differences of sex development in which the development of chromosomal, gonadal, or anatomic sex is atypical. Examples of these conditions are congenital adrenal hyperplasia and androgen insensitivity syndrome. Gender includes the behavioral, cultural, and psychological characteristics associated with femaleness or maleness.2 Gender identity is a person’s innate sense of feeling male, female, or somewhere in between. Individuals who have a gender identity that is congruent with their assigned sex are referred to as cisgender; those who have a gender identity that does not align with their birth sex are often referred to as transgender. Gender expression is how people choose to present themselves to the world. A person’s gender may or may not be consistent with his/her internal gender identity. For example, an individual may be female biologically (XX chromosomes, with a uterus, ovaries, and vagina) and self-identify as female, but express herself in a masculine way by having her hair cut short and wearing more masculine clothing.
Gender dysphoria occurs when an individual experiences psychological distress caused by the incongruence between his/her biologic sex and his/her internal gender identity, and this mismatch leads to clinically significant distress or impairment in daily functioning. Gender dysphoria is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It has replaced the earlier diagnosis of gender identity disorder in the DSM-IV. The new diagnosis focuses on the distress related to an incongruence between gender identity and biologic sex and does not label it as pathologic. Gender-nonconforming individuals do not follow other people’s ideas or stereotypes about how they should look or act based on the sex they were assigned at birth. It is important to note that an individual’s gender identity is separate from sexual orientation. Sexual orientation describes an individual’s pattern of sexual and physical attraction. An individual may be attracted to members of the same sex (homosexual, lesbian, gay), opposite sex (heterosexual), or both sexes (bisexual). Increasingly youth are using a variety of terms to describe their gender (for example, genderqueer, asexual, gender fluid) and sexual orientation (for example, pansexual, asexual). These terms may have different meanings for different youth, and it is important to respectfully ask and clarify what these terms mean to each individual patient.
Trajectory of gender identity
Experimenting with gender expression and gender roles is a normal part of childhood. The majority of young children with nonconforming gender identification will not persist with this identification through adolescence. Some of these children will go on to have a nonheterosexual sexual orientation when they are older. While it can be difficult to predict the trajectory of cross-gender identification in early childhood, those with a persistent, insistent, and consistent cross-gender identification in childhood are more likely to experience gender dysphoria and continue with a transgender identity into adulthood. Adolescence is a particularly difficult time for GN youth. The development of secondary sex characteristics that are not consistent with an individual’s identified gender, in addition to the psychosocial challenges of adolescent development, can lead to increased suicidal thoughts, self-harm behaviors, anxiety, isolation, and risk-taking behaviors. Gender dysphoria that increases with the onset of puberty rarely subsides with time.
Approach to GN patients in practice
Research is ongoing related to best practices for the care of GN youth. Clinical guidelines and standards of care have been published and endorsed by organizations including the Endocrine Society, Pediatric Endocrine Society, World Professional Association for Transgender Health, and the American Academy of Pediatrics. My recommendations for the care of GN youth are based on these guidelines.
Primary care providers are often the first place families turn when a child experiences gender identity concerns. Primary care providers can play an important role in providing a safe nonjudgmental environment for patients and families to discuss their concerns, and connecting patients and families to appropriate resources. Providers should first work to educate themselves and their staff about issues affecting GN youth and learn to provide culturally competent care to these youth. Asking youth their preferred names and preferred pronouns (for example, “he/him/his,” “she/her/hers,” “they/them/their,” or something else), documenting this in the medical record, and training clinic staff to use preferred names and pronouns creates an environment that validates, supports, and respects these youth.
It is important to ask all adolescents if they have questions or concerns about their gender identity, in addition to asking questions about sexual identity. It is important when asking these questions to avoid assumptions about an individual’s gender identity based on his or her gender expression. Providers also should familiarize themselves with local referral resources for these youth. As mentioned earlier, GN youth are at high risk for mental health complications including suicide, self-harm, and mood disorders. When referring patients for mental health services, you should be familiar with providers who have expertise in issues of gender identity. A recent report by the Substance Abuse and Mental Health Services Administration states that variations in gender identity are normal, and conversion therapies or other efforts to change gender identity are not effective, are harmful, and are not appropriate therapeutic practices.4
As increasing numbers of youth are identifying as transgender or gender nonconforming, the number of clinics that can coordinate with local providers to provide multidisciplinary care for GN patients is growing.
Resources for health care professionals
• National LGBT Health Education Center, the Fenway Institute. At its website, learning modules, webinars, and other educational resources are available for health care organizations.
• World Professional Association of Transgender Health. This website provides standards of care for transgender patients and a provider directory.
• The Genderbread Person. This website has a helpful infographic illustrating differences between biologic sex, gender identity, gender expression, and sexual orientation, which can be useful for education with patients, families, and trainees.
• Center of Excellence for Transgender Health. This organization works to increase access to comprehensive, effective, and affirming health care services for trans communities.
Resources for patients and families
• The Trevor Project. This website provides crisis intervention and suicide prevention services.
• National Center for Transgender Equality. This advocacy organization works to promote policy change to advance transgender equality.
• Family Acceptance Project. This research, intervention, education, and policy initiative works to prevent health and mental health risks for lesbian, gay, bisexual, and transgender children and youth, including suicide, homelessness, and HIV – in the context of their families, cultures, and faith communities.
References
1. Pediatrics. 2012 Mar;129(3):418-25.
2. Pediatrics. 2014 Dec;134(6):1184-92.
3. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV, Lambda Legal, 2010. Available at www.lambdalegal.org/health-care-report.
4. Substance Abuse and Mental Health Services Administration. Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth. HHS Publication No. (SMA) 15-4928. October 2015. Available at http://store.samhsa.gov/shin/content//SMA15-4928/SMA15-4928.pdf.
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.
A primer on sexuality and gender identity
I am a relatively young physician. When I started medical school 10 years ago, I thought that most medical school campuses would be fairly progressive. This was not the case for me.
My school did not have a nondiscrimination policy on sexual orientation or gender identity at the time, nor do I recall any lectures about this patient population. So during my first year of medical school, I embarked on a mission to educate both my classmates and the faculty about sexual orientation, gender identity, and related health disparities. My fellow classmates and the administration received my efforts warmly; nevertheless, this effort to educate was an incredible challenge for me. Surely other medical school campuses were already discussing the importance of sexuality and gender identity, I thought.
Fast forward to the year 2011. A study in JAMA found that many medical schools fall short in teaching the next generation of physicians about lesbian, gay, bisexual, and transgender (LGBT) health (JAMA. 2011;306[9]:971-7).
Things may have improved for LGBT people, but the world of medicine has yet to catch up. If LGBT medical education is lacking today, imagine how lacking it was for those who went to medical school decades ago. It is my hope that with this new column, we as a medical community can make up for lost time.
Why should physicians, especially pediatricians, care about LGBT health? Although LGBT youth comprise less than 10% of the adolescent population, they have a disproportionate share of health problems compared with their heterosexual peers. LGBT youth are three times as likely to attempt suicide and almost two times as likely to abuse alcohol and drugs compared with heterosexual youth. Among homeless teens in the United States, a whopping 40% are LGBT. HIV still plagues young gay males – especially those of color – and young gay and bisexual women experience an inordinate amount of dating violence from both men and women. Most appalling of all, every 3 days, a transgender person is murdered. These sobering statistics highlight the impact sexual orientation and gender identity have on health.
Why do LGBT youth experience such enormous health problems? A rich body of evidence points to stigma and discrimination as a likely cause. We are familiar with stories of how LGBT youth are kicked out of their homes after coming out to their parents or how male teens suffered bullying for being perceived as “too feminine.” Nonetheless, we tend to ignore the more subtle ways LGBT youth experience stigma and discrimination through our heterosexist language and behavior. Although we could dismiss the phrase “that’s so gay” as just another variation of “that’s so dumb,” an LGBT teen might think “if something is that dumb, then so am I.”
My fellow columnists and I hope that this column will help you get to know a very vulnerable, yet special, population. We will ask you to rethink what you have learned about sexuality and gender. Here, we will start with the basics.
What is the difference between sex and gender?
Sex is the biological distinction between male and female that is determined chromosomally (XX versus XY, although there are variations) and phenotypically, such as organs like the penis or vagina. Gender is a range of characteristics that a culture assigns as typically male and female, which encompasses both anatomy and behaviors. For example, an individual assigned as male because he was born with a penis is also expected to be proactive, a problem solver, stoic, and the breadwinner of the family. Although we’d like to believe that there are clear distinctions between the two solely on the basis of anatomy, we often see many people diverge from behaviors that are typically assigned to a gender. In modern day U.S. society, there are an increasing number of men who stay home to take care of their children – a typically female role. In other words, gender is a spectrum ranging from the very masculine to the very feminine and everything else in between.
What is gender identity?
Gender identity is our own sense of maleness or femaleness. This identity can be based on a variety of factors, including the sex organ one is born with and the culture one is raised in. It also is possible for some people to feel that they do not fit neatly into male or female categories. At the end of the day, only you can determine your gender identity, despite beliefs and attitudes in society about which appearances and behaviors are stereotypically male or female.
Transgender people are individuals who experience a mismatch between their gender identity and their assigned sex at birth. The word “trans” is Latin for “the other side,” highlighting the discrepancy between one’s gender identity and assigned sex. In contrast, people who identify as their assigned sex would be called cisgender. The word “cis” is Latin for “the same side.” A transgender male is someone who was assigned female at birth, but identifies as a male, whereas a transgender female is someone who was assigned male at birth, but identifies as a female. You also may also hear the terms “FTM” (female to male) and “MTF” (male to female) to describe transgender males and females, respectively.
What is sexual orientation?
Sexual orientation refers to our pattern of emotional and/or physical attraction to people who are the same or the opposite gender. The most common in this society is heterosexual, where one finds the opposite gender attractive. Those who identify as gay or lesbian find the same gender attractive. A person who identifies as bisexual finds both genders attractive. There are other sexual orientations that are not as commonly known. Someone who is pansexual is attracted to any sex or gender identity. Asexuals are individuals who don’t find anyone sexually attractive, but could be attracted to someone romantically or emotionally irrespective of sex or gender.
Just as gender is fluid, so is sexuality. Alfred Kinsey, a well-known sexologist, introduced the concept of sexual fluidity with the Kinsey Scale. With this scale, people rate themselves on how attracted they are to each sex, ranging from 0 – meaning exclusively attracted to the opposite sex – to 3 – equally attracted to both sexes – to 6 – exclusively attracted to the same sex. It is possible to move along the spectrum in either direction over time or stay in one place. It is also possible for our sexual identity (i.e. lesbian, gay, bisexual) and sexual behavior (i.e. whom we are having sex with) to not perfectly overlap; attraction is complex. Finally, people often confuse gender identity and sexual orientation. These are two separate concepts and not dependent on each other. For example, someone who was assigned female at birth but now identifies as male can still be attracted to men.
This primer is by no means complete or comprehensive and runs the risk of being oversimplistic. Nevertheless, I hope it will get you thinking about the nature of sexuality and gender identity and how they affect health. In the next couple of months, you will read more on the complexities of sexuality and gender identity, advice on how to talk to your patients about these topics, how to make your clinic a safe place for LGBT youth, the transition process for transgender youth, and much more. I encourage you stick around to learn how you can help this vulnerable, but amazing, group of young people. Until next time …
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh.
I am a relatively young physician. When I started medical school 10 years ago, I thought that most medical school campuses would be fairly progressive. This was not the case for me.
My school did not have a nondiscrimination policy on sexual orientation or gender identity at the time, nor do I recall any lectures about this patient population. So during my first year of medical school, I embarked on a mission to educate both my classmates and the faculty about sexual orientation, gender identity, and related health disparities. My fellow classmates and the administration received my efforts warmly; nevertheless, this effort to educate was an incredible challenge for me. Surely other medical school campuses were already discussing the importance of sexuality and gender identity, I thought.
Fast forward to the year 2011. A study in JAMA found that many medical schools fall short in teaching the next generation of physicians about lesbian, gay, bisexual, and transgender (LGBT) health (JAMA. 2011;306[9]:971-7).
Things may have improved for LGBT people, but the world of medicine has yet to catch up. If LGBT medical education is lacking today, imagine how lacking it was for those who went to medical school decades ago. It is my hope that with this new column, we as a medical community can make up for lost time.
Why should physicians, especially pediatricians, care about LGBT health? Although LGBT youth comprise less than 10% of the adolescent population, they have a disproportionate share of health problems compared with their heterosexual peers. LGBT youth are three times as likely to attempt suicide and almost two times as likely to abuse alcohol and drugs compared with heterosexual youth. Among homeless teens in the United States, a whopping 40% are LGBT. HIV still plagues young gay males – especially those of color – and young gay and bisexual women experience an inordinate amount of dating violence from both men and women. Most appalling of all, every 3 days, a transgender person is murdered. These sobering statistics highlight the impact sexual orientation and gender identity have on health.
Why do LGBT youth experience such enormous health problems? A rich body of evidence points to stigma and discrimination as a likely cause. We are familiar with stories of how LGBT youth are kicked out of their homes after coming out to their parents or how male teens suffered bullying for being perceived as “too feminine.” Nonetheless, we tend to ignore the more subtle ways LGBT youth experience stigma and discrimination through our heterosexist language and behavior. Although we could dismiss the phrase “that’s so gay” as just another variation of “that’s so dumb,” an LGBT teen might think “if something is that dumb, then so am I.”
My fellow columnists and I hope that this column will help you get to know a very vulnerable, yet special, population. We will ask you to rethink what you have learned about sexuality and gender. Here, we will start with the basics.
What is the difference between sex and gender?
Sex is the biological distinction between male and female that is determined chromosomally (XX versus XY, although there are variations) and phenotypically, such as organs like the penis or vagina. Gender is a range of characteristics that a culture assigns as typically male and female, which encompasses both anatomy and behaviors. For example, an individual assigned as male because he was born with a penis is also expected to be proactive, a problem solver, stoic, and the breadwinner of the family. Although we’d like to believe that there are clear distinctions between the two solely on the basis of anatomy, we often see many people diverge from behaviors that are typically assigned to a gender. In modern day U.S. society, there are an increasing number of men who stay home to take care of their children – a typically female role. In other words, gender is a spectrum ranging from the very masculine to the very feminine and everything else in between.
What is gender identity?
Gender identity is our own sense of maleness or femaleness. This identity can be based on a variety of factors, including the sex organ one is born with and the culture one is raised in. It also is possible for some people to feel that they do not fit neatly into male or female categories. At the end of the day, only you can determine your gender identity, despite beliefs and attitudes in society about which appearances and behaviors are stereotypically male or female.
Transgender people are individuals who experience a mismatch between their gender identity and their assigned sex at birth. The word “trans” is Latin for “the other side,” highlighting the discrepancy between one’s gender identity and assigned sex. In contrast, people who identify as their assigned sex would be called cisgender. The word “cis” is Latin for “the same side.” A transgender male is someone who was assigned female at birth, but identifies as a male, whereas a transgender female is someone who was assigned male at birth, but identifies as a female. You also may also hear the terms “FTM” (female to male) and “MTF” (male to female) to describe transgender males and females, respectively.
What is sexual orientation?
Sexual orientation refers to our pattern of emotional and/or physical attraction to people who are the same or the opposite gender. The most common in this society is heterosexual, where one finds the opposite gender attractive. Those who identify as gay or lesbian find the same gender attractive. A person who identifies as bisexual finds both genders attractive. There are other sexual orientations that are not as commonly known. Someone who is pansexual is attracted to any sex or gender identity. Asexuals are individuals who don’t find anyone sexually attractive, but could be attracted to someone romantically or emotionally irrespective of sex or gender.
Just as gender is fluid, so is sexuality. Alfred Kinsey, a well-known sexologist, introduced the concept of sexual fluidity with the Kinsey Scale. With this scale, people rate themselves on how attracted they are to each sex, ranging from 0 – meaning exclusively attracted to the opposite sex – to 3 – equally attracted to both sexes – to 6 – exclusively attracted to the same sex. It is possible to move along the spectrum in either direction over time or stay in one place. It is also possible for our sexual identity (i.e. lesbian, gay, bisexual) and sexual behavior (i.e. whom we are having sex with) to not perfectly overlap; attraction is complex. Finally, people often confuse gender identity and sexual orientation. These are two separate concepts and not dependent on each other. For example, someone who was assigned female at birth but now identifies as male can still be attracted to men.
This primer is by no means complete or comprehensive and runs the risk of being oversimplistic. Nevertheless, I hope it will get you thinking about the nature of sexuality and gender identity and how they affect health. In the next couple of months, you will read more on the complexities of sexuality and gender identity, advice on how to talk to your patients about these topics, how to make your clinic a safe place for LGBT youth, the transition process for transgender youth, and much more. I encourage you stick around to learn how you can help this vulnerable, but amazing, group of young people. Until next time …
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh.
I am a relatively young physician. When I started medical school 10 years ago, I thought that most medical school campuses would be fairly progressive. This was not the case for me.
My school did not have a nondiscrimination policy on sexual orientation or gender identity at the time, nor do I recall any lectures about this patient population. So during my first year of medical school, I embarked on a mission to educate both my classmates and the faculty about sexual orientation, gender identity, and related health disparities. My fellow classmates and the administration received my efforts warmly; nevertheless, this effort to educate was an incredible challenge for me. Surely other medical school campuses were already discussing the importance of sexuality and gender identity, I thought.
Fast forward to the year 2011. A study in JAMA found that many medical schools fall short in teaching the next generation of physicians about lesbian, gay, bisexual, and transgender (LGBT) health (JAMA. 2011;306[9]:971-7).
Things may have improved for LGBT people, but the world of medicine has yet to catch up. If LGBT medical education is lacking today, imagine how lacking it was for those who went to medical school decades ago. It is my hope that with this new column, we as a medical community can make up for lost time.
Why should physicians, especially pediatricians, care about LGBT health? Although LGBT youth comprise less than 10% of the adolescent population, they have a disproportionate share of health problems compared with their heterosexual peers. LGBT youth are three times as likely to attempt suicide and almost two times as likely to abuse alcohol and drugs compared with heterosexual youth. Among homeless teens in the United States, a whopping 40% are LGBT. HIV still plagues young gay males – especially those of color – and young gay and bisexual women experience an inordinate amount of dating violence from both men and women. Most appalling of all, every 3 days, a transgender person is murdered. These sobering statistics highlight the impact sexual orientation and gender identity have on health.
Why do LGBT youth experience such enormous health problems? A rich body of evidence points to stigma and discrimination as a likely cause. We are familiar with stories of how LGBT youth are kicked out of their homes after coming out to their parents or how male teens suffered bullying for being perceived as “too feminine.” Nonetheless, we tend to ignore the more subtle ways LGBT youth experience stigma and discrimination through our heterosexist language and behavior. Although we could dismiss the phrase “that’s so gay” as just another variation of “that’s so dumb,” an LGBT teen might think “if something is that dumb, then so am I.”
My fellow columnists and I hope that this column will help you get to know a very vulnerable, yet special, population. We will ask you to rethink what you have learned about sexuality and gender. Here, we will start with the basics.
What is the difference between sex and gender?
Sex is the biological distinction between male and female that is determined chromosomally (XX versus XY, although there are variations) and phenotypically, such as organs like the penis or vagina. Gender is a range of characteristics that a culture assigns as typically male and female, which encompasses both anatomy and behaviors. For example, an individual assigned as male because he was born with a penis is also expected to be proactive, a problem solver, stoic, and the breadwinner of the family. Although we’d like to believe that there are clear distinctions between the two solely on the basis of anatomy, we often see many people diverge from behaviors that are typically assigned to a gender. In modern day U.S. society, there are an increasing number of men who stay home to take care of their children – a typically female role. In other words, gender is a spectrum ranging from the very masculine to the very feminine and everything else in between.
What is gender identity?
Gender identity is our own sense of maleness or femaleness. This identity can be based on a variety of factors, including the sex organ one is born with and the culture one is raised in. It also is possible for some people to feel that they do not fit neatly into male or female categories. At the end of the day, only you can determine your gender identity, despite beliefs and attitudes in society about which appearances and behaviors are stereotypically male or female.
Transgender people are individuals who experience a mismatch between their gender identity and their assigned sex at birth. The word “trans” is Latin for “the other side,” highlighting the discrepancy between one’s gender identity and assigned sex. In contrast, people who identify as their assigned sex would be called cisgender. The word “cis” is Latin for “the same side.” A transgender male is someone who was assigned female at birth, but identifies as a male, whereas a transgender female is someone who was assigned male at birth, but identifies as a female. You also may also hear the terms “FTM” (female to male) and “MTF” (male to female) to describe transgender males and females, respectively.
What is sexual orientation?
Sexual orientation refers to our pattern of emotional and/or physical attraction to people who are the same or the opposite gender. The most common in this society is heterosexual, where one finds the opposite gender attractive. Those who identify as gay or lesbian find the same gender attractive. A person who identifies as bisexual finds both genders attractive. There are other sexual orientations that are not as commonly known. Someone who is pansexual is attracted to any sex or gender identity. Asexuals are individuals who don’t find anyone sexually attractive, but could be attracted to someone romantically or emotionally irrespective of sex or gender.
Just as gender is fluid, so is sexuality. Alfred Kinsey, a well-known sexologist, introduced the concept of sexual fluidity with the Kinsey Scale. With this scale, people rate themselves on how attracted they are to each sex, ranging from 0 – meaning exclusively attracted to the opposite sex – to 3 – equally attracted to both sexes – to 6 – exclusively attracted to the same sex. It is possible to move along the spectrum in either direction over time or stay in one place. It is also possible for our sexual identity (i.e. lesbian, gay, bisexual) and sexual behavior (i.e. whom we are having sex with) to not perfectly overlap; attraction is complex. Finally, people often confuse gender identity and sexual orientation. These are two separate concepts and not dependent on each other. For example, someone who was assigned female at birth but now identifies as male can still be attracted to men.
This primer is by no means complete or comprehensive and runs the risk of being oversimplistic. Nevertheless, I hope it will get you thinking about the nature of sexuality and gender identity and how they affect health. In the next couple of months, you will read more on the complexities of sexuality and gender identity, advice on how to talk to your patients about these topics, how to make your clinic a safe place for LGBT youth, the transition process for transgender youth, and much more. I encourage you stick around to learn how you can help this vulnerable, but amazing, group of young people. Until next time …
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh.
