LGBT Youth Consult

For many, the holiday season is a time to celebrate, relax, and enjoy the company of family. Much of this celebrating centers on eating and food. For youth struggling with eating disorders, holidays can be a particularly challenging time. Historically, eating disorders were associated with young, straight, cisgender, white females. Data collected over the past 15 years suggest that eating disorders can affect youth of all ethnicities and genders.

Ingram Publishing/ThinkStock

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Resources

National Eating Disorders Association: www.nationaleatingdisorders.org

“Body image and eating disorders among lesbian, gay, bisexual, and transgender youth” (Pediatr Clin North Am. 2016 Dec;63[6]:1079-90.

References

1. Prev Chronic Dis. 2008 Oct;5(4):A114.

2. Arch Gen Psychiatry. 2011 Jul;68(7):714-23.

3. Pediatr Clin North Am. 2016 Dec;63(6):1079-90.

4. Curr Psychiatry Rep. 2012 Aug;14(4):391-7.

5. J Adolesc Health. 2015 Aug;57(2):144-9.

6. Am J Public Health. 2013 Feb;103(2):e16-22.

7. J Adolesc Health. 2009 Sep;45(3):238-45.
 

For many, the holiday season is a time to celebrate, relax, and enjoy the company of family. Much of this celebrating centers on eating and food. For youth struggling with eating disorders, holidays can be a particularly challenging time. Historically, eating disorders were associated with young, straight, cisgender, white females. Data collected over the past 15 years suggest that eating disorders can affect youth of all ethnicities and genders.

Ingram Publishing/ThinkStock

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Resources

National Eating Disorders Association: www.nationaleatingdisorders.org

“Body image and eating disorders among lesbian, gay, bisexual, and transgender youth” (Pediatr Clin North Am. 2016 Dec;63[6]:1079-90.

References

1. Prev Chronic Dis. 2008 Oct;5(4):A114.

2. Arch Gen Psychiatry. 2011 Jul;68(7):714-23.

3. Pediatr Clin North Am. 2016 Dec;63(6):1079-90.

4. Curr Psychiatry Rep. 2012 Aug;14(4):391-7.

5. J Adolesc Health. 2015 Aug;57(2):144-9.

6. Am J Public Health. 2013 Feb;103(2):e16-22.

7. J Adolesc Health. 2009 Sep;45(3):238-45.
 

For many, the holiday season is a time to celebrate, relax, and enjoy the company of family. Much of this celebrating centers on eating and food. For youth struggling with eating disorders, holidays can be a particularly challenging time. Historically, eating disorders were associated with young, straight, cisgender, white females. Data collected over the past 15 years suggest that eating disorders can affect youth of all ethnicities and genders.

Ingram Publishing/ThinkStock

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Resources

National Eating Disorders Association: www.nationaleatingdisorders.org

“Body image and eating disorders among lesbian, gay, bisexual, and transgender youth” (Pediatr Clin North Am. 2016 Dec;63[6]:1079-90.

References

1. Prev Chronic Dis. 2008 Oct;5(4):A114.

2. Arch Gen Psychiatry. 2011 Jul;68(7):714-23.

3. Pediatr Clin North Am. 2016 Dec;63(6):1079-90.

4. Curr Psychiatry Rep. 2012 Aug;14(4):391-7.

5. J Adolesc Health. 2015 Aug;57(2):144-9.

6. Am J Public Health. 2013 Feb;103(2):e16-22.

7. J Adolesc Health. 2009 Sep;45(3):238-45.
 

Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.¹ Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.

JackF/Thinkstock

Obtaining a sexual history

1. Clearly explain the reasons for asking sexually explicit questions.

TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.

2. Ensure confidentiality.

When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.^2,3 The Guttmacher Institute provides information about minors’ consent law in each state.⁴

3. Do not assume identity equals behavior.

Sexual and gender identity may not be predictive of sexual behaviors, and providers should not assume behaviors based on a patient’s identity.

Here are some sexual health questions you need to ask:

• Who are you attracted to? What is/are the gender(s) of your partner(s)?
• Have you ever had anal, genital, or oral sex? If yes:

Do you give, receive, or both?

When was the last time you had sex?

How many partners have you had in past 6 months?

Do you use barrier protection most of the time, some of the time, always, or never?

Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?

• Have you ever been forced/coerced into having sex?

Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.

4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit

Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.⁵ For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.⁶
 

Physical exam

Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).^1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.

Sexual health counseling

Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.⁹ In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.

Email her at pdnews@frontlinemedcom.com.

References

1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, in Center of Excellence for Transgender Health, Department of Family and Community Medicine, 2nd ed. (San Francisco: University of California, 2016).

2. Pediatrics. 2008. doi: 10.1542/peds.2008-0694.

3. J Adol Health. 2004;35:160-7.

4. An Overview of Minors’ Consent Law: State Laws and Policies. 2017, by the Guttmacher Institute.

5. Eur J Endocrinol. 2011 Aug;165(2):331-7.

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

7. Sex Roles. 2013 Jun 1;68(11-12):675-89.

8. J Midwifery Womens Health. 2008 Jul-Aug;53(4):331-7.

9. “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,” 2nd ed. (Philadelphia: American College of Physicians Press, 2008).

Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.¹ Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.

JackF/Thinkstock

Obtaining a sexual history

1. Clearly explain the reasons for asking sexually explicit questions.

TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.

2. Ensure confidentiality.

When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.^2,3 The Guttmacher Institute provides information about minors’ consent law in each state.⁴

3. Do not assume identity equals behavior.

Sexual and gender identity may not be predictive of sexual behaviors, and providers should not assume behaviors based on a patient’s identity.

Here are some sexual health questions you need to ask:

• Who are you attracted to? What is/are the gender(s) of your partner(s)?
• Have you ever had anal, genital, or oral sex? If yes:

Do you give, receive, or both?

When was the last time you had sex?

How many partners have you had in past 6 months?

Do you use barrier protection most of the time, some of the time, always, or never?

Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?

• Have you ever been forced/coerced into having sex?

Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.

4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit

Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.⁵ For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.⁶
 

Physical exam

Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).^1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.

Sexual health counseling

Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.⁹ In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.

Email her at pdnews@frontlinemedcom.com.

References

1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, in Center of Excellence for Transgender Health, Department of Family and Community Medicine, 2nd ed. (San Francisco: University of California, 2016).

2. Pediatrics. 2008. doi: 10.1542/peds.2008-0694.

3. J Adol Health. 2004;35:160-7.

4. An Overview of Minors’ Consent Law: State Laws and Policies. 2017, by the Guttmacher Institute.

5. Eur J Endocrinol. 2011 Aug;165(2):331-7.

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

7. Sex Roles. 2013 Jun 1;68(11-12):675-89.

8. J Midwifery Womens Health. 2008 Jul-Aug;53(4):331-7.

9. “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,” 2nd ed. (Philadelphia: American College of Physicians Press, 2008).

Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.¹ Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.

JackF/Thinkstock

Obtaining a sexual history

1. Clearly explain the reasons for asking sexually explicit questions.

TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.

2. Ensure confidentiality.

When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.^2,3 The Guttmacher Institute provides information about minors’ consent law in each state.⁴

3. Do not assume identity equals behavior.

Sexual and gender identity may not be predictive of sexual behaviors, and providers should not assume behaviors based on a patient’s identity.

Here are some sexual health questions you need to ask:

• Who are you attracted to? What is/are the gender(s) of your partner(s)?
• Have you ever had anal, genital, or oral sex? If yes:

Do you give, receive, or both?

When was the last time you had sex?

How many partners have you had in past 6 months?

Do you use barrier protection most of the time, some of the time, always, or never?

Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?

• Have you ever been forced/coerced into having sex?

Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.

4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit

Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.⁵ For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.⁶
 

Physical exam

Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).^1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.

Sexual health counseling

Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.⁹ In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.

Email her at pdnews@frontlinemedcom.com.

References

1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, in Center of Excellence for Transgender Health, Department of Family and Community Medicine, 2nd ed. (San Francisco: University of California, 2016).

2. Pediatrics. 2008. doi: 10.1542/peds.2008-0694.

3. J Adol Health. 2004;35:160-7.

4. An Overview of Minors’ Consent Law: State Laws and Policies. 2017, by the Guttmacher Institute.

5. Eur J Endocrinol. 2011 Aug;165(2):331-7.

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

7. Sex Roles. 2013 Jun 1;68(11-12):675-89.

8. J Midwifery Womens Health. 2008 Jul-Aug;53(4):331-7.

9. “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,” 2nd ed. (Philadelphia: American College of Physicians Press, 2008).

It may be unusual for an LGBT health columnist to mention the horrendous events that occurred in Charlottesville, Va., in August 2017. It clearly was a demonstration of hate and violence against racial and ethnic minorities. Unfortunately, the LGBT community – especially LGBT communities of color – are often a target of that kind of hate and violence. This has a detrimental effect on the health of the LGBT community, and I believe that health care providers have a responsibility to address this hate and violence to promote the well-being of this marginalized community.

It cannot be overstated that LGBT individuals frequently experience anti-gay and anti-trans violence. According to the 2015 Federal Bureau of Investigation Hate Crime Statistics, about a fifth of hate crimes reported were based on sexual orientation or gender identity.¹ In addition, LGBT youth are eight times as likely to experience bullying at school because of their sexual orientation or gender identity.² Furthermore, on many surveys on anti-LGBT violence, people of color comprise more than half of the victims.³ There is a strong association between exposure to this violence and the health outcomes of LGBT youth. A study by Russell et al. showed that LGBT youth who were victims of physical violence at school are more likely to be depressed and suicidal and more likely to be diagnosed with an STD,⁴ and another study showed that LGBT youth who experienced anti-LGBT violence are more likely to engage in substance use.⁵ The health outcomes from anti-LGBT violence are not limited to the adolescent period – adolescents who experienced this kind of violence are more likely to report higher levels of depression as adults.⁶ Although researchers still are trying to determine the exact mechanism for these relationships, the most cited (and sensible) explanation is that exposure to anti-LGBT stigma, discrimination, and violence leads to a toxic environment, which in turn increases the risk for mental health problems and maladaptive coping mechanisms (such as substance use) as a response to such an environment.⁷

Resources

• Advocates for Youth. Creating Safe Space for GLBTQ Youth: A Toolkit

• Human Rights Campaign. www.hrc.org/resources/

• American Academy of Pediatrics advocacy page: www.aap.org/en-us/advocacy-and-policy/

References

1. U.S. Department of Justice Federal Bureau of Investigation. Uniform Crime Report Hate Crime Statistics, 2015.

2. J Interpers Violence. 2017. doi: 10.1177/0886260517718830.

3. National Coalition of Anti-Violence Programs (NCAVP). Lesbian, Gay, Bisexual, Transgender, Queer and HIV-Affected Hate Violence in 2016.

4. J Sch Health. 2011 May;81(5):223-30.

5. Prev Sci. 2015 Jul;16(5):734-43.

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

7. Psychol Bull. 2003 Sep;129(5):674-97.

8. Gallup. Americans Rate Healthcare Providers High on Honesty, Ethics. 2016.

9. The Hippocratic Oath Today. 2001 or Do. No. Harm.

It may be unusual for an LGBT health columnist to mention the horrendous events that occurred in Charlottesville, Va., in August 2017. It clearly was a demonstration of hate and violence against racial and ethnic minorities. Unfortunately, the LGBT community – especially LGBT communities of color – are often a target of that kind of hate and violence. This has a detrimental effect on the health of the LGBT community, and I believe that health care providers have a responsibility to address this hate and violence to promote the well-being of this marginalized community.

It cannot be overstated that LGBT individuals frequently experience anti-gay and anti-trans violence. According to the 2015 Federal Bureau of Investigation Hate Crime Statistics, about a fifth of hate crimes reported were based on sexual orientation or gender identity.¹ In addition, LGBT youth are eight times as likely to experience bullying at school because of their sexual orientation or gender identity.² Furthermore, on many surveys on anti-LGBT violence, people of color comprise more than half of the victims.³ There is a strong association between exposure to this violence and the health outcomes of LGBT youth. A study by Russell et al. showed that LGBT youth who were victims of physical violence at school are more likely to be depressed and suicidal and more likely to be diagnosed with an STD,⁴ and another study showed that LGBT youth who experienced anti-LGBT violence are more likely to engage in substance use.⁵ The health outcomes from anti-LGBT violence are not limited to the adolescent period – adolescents who experienced this kind of violence are more likely to report higher levels of depression as adults.⁶ Although researchers still are trying to determine the exact mechanism for these relationships, the most cited (and sensible) explanation is that exposure to anti-LGBT stigma, discrimination, and violence leads to a toxic environment, which in turn increases the risk for mental health problems and maladaptive coping mechanisms (such as substance use) as a response to such an environment.⁷

Resources

• Advocates for Youth. Creating Safe Space for GLBTQ Youth: A Toolkit

• Human Rights Campaign. www.hrc.org/resources/

• American Academy of Pediatrics advocacy page: www.aap.org/en-us/advocacy-and-policy/

References

1. U.S. Department of Justice Federal Bureau of Investigation. Uniform Crime Report Hate Crime Statistics, 2015.

2. J Interpers Violence. 2017. doi: 10.1177/0886260517718830.

3. National Coalition of Anti-Violence Programs (NCAVP). Lesbian, Gay, Bisexual, Transgender, Queer and HIV-Affected Hate Violence in 2016.

4. J Sch Health. 2011 May;81(5):223-30.

5. Prev Sci. 2015 Jul;16(5):734-43.

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

7. Psychol Bull. 2003 Sep;129(5):674-97.

8. Gallup. Americans Rate Healthcare Providers High on Honesty, Ethics. 2016.

9. The Hippocratic Oath Today. 2001 or Do. No. Harm.

It may be unusual for an LGBT health columnist to mention the horrendous events that occurred in Charlottesville, Va., in August 2017. It clearly was a demonstration of hate and violence against racial and ethnic minorities. Unfortunately, the LGBT community – especially LGBT communities of color – are often a target of that kind of hate and violence. This has a detrimental effect on the health of the LGBT community, and I believe that health care providers have a responsibility to address this hate and violence to promote the well-being of this marginalized community.

It cannot be overstated that LGBT individuals frequently experience anti-gay and anti-trans violence. According to the 2015 Federal Bureau of Investigation Hate Crime Statistics, about a fifth of hate crimes reported were based on sexual orientation or gender identity.¹ In addition, LGBT youth are eight times as likely to experience bullying at school because of their sexual orientation or gender identity.² Furthermore, on many surveys on anti-LGBT violence, people of color comprise more than half of the victims.³ There is a strong association between exposure to this violence and the health outcomes of LGBT youth. A study by Russell et al. showed that LGBT youth who were victims of physical violence at school are more likely to be depressed and suicidal and more likely to be diagnosed with an STD,⁴ and another study showed that LGBT youth who experienced anti-LGBT violence are more likely to engage in substance use.⁵ The health outcomes from anti-LGBT violence are not limited to the adolescent period – adolescents who experienced this kind of violence are more likely to report higher levels of depression as adults.⁶ Although researchers still are trying to determine the exact mechanism for these relationships, the most cited (and sensible) explanation is that exposure to anti-LGBT stigma, discrimination, and violence leads to a toxic environment, which in turn increases the risk for mental health problems and maladaptive coping mechanisms (such as substance use) as a response to such an environment.⁷

Resources

• Advocates for Youth. Creating Safe Space for GLBTQ Youth: A Toolkit

• Human Rights Campaign. www.hrc.org/resources/

• American Academy of Pediatrics advocacy page: www.aap.org/en-us/advocacy-and-policy/

References

1. U.S. Department of Justice Federal Bureau of Investigation. Uniform Crime Report Hate Crime Statistics, 2015.

2. J Interpers Violence. 2017. doi: 10.1177/0886260517718830.

3. National Coalition of Anti-Violence Programs (NCAVP). Lesbian, Gay, Bisexual, Transgender, Queer and HIV-Affected Hate Violence in 2016.

4. J Sch Health. 2011 May;81(5):223-30.

5. Prev Sci. 2015 Jul;16(5):734-43.

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

7. Psychol Bull. 2003 Sep;129(5):674-97.

8. Gallup. Americans Rate Healthcare Providers High on Honesty, Ethics. 2016.

9. The Hippocratic Oath Today. 2001 or Do. No. Harm.

JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.

Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.¹ For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.

Design Pics/Thinkstock

• Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
• LGBT people exist in almost every faith group across the country.
• Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
• Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
• While every religion has different teachings, almost all religions advocate love and compassion.
• Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
• Remember this is your journey. You get to decide the path and the pace.
• Recognize that this may involve working for change within your community or it may mean leaving it.
• Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Spirituality resources

• LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
• Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
• LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
• HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith

References

1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).

2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)

3. Pediatrics. 2013 Jul;132(1):198-203.

4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)

5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.

JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.

Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.¹ For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.

Design Pics/Thinkstock

• Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
• LGBT people exist in almost every faith group across the country.
• Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
• Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
• While every religion has different teachings, almost all religions advocate love and compassion.
• Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
• Remember this is your journey. You get to decide the path and the pace.
• Recognize that this may involve working for change within your community or it may mean leaving it.
• Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Spirituality resources

• LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
• Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
• LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
• HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith

References

1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).

2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)

3. Pediatrics. 2013 Jul;132(1):198-203.

4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)

5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.

JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.

Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.¹ For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.

Design Pics/Thinkstock

• Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
• LGBT people exist in almost every faith group across the country.
• Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
• Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
• While every religion has different teachings, almost all religions advocate love and compassion.
• Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
• Remember this is your journey. You get to decide the path and the pace.
• Recognize that this may involve working for change within your community or it may mean leaving it.
• Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Spirituality resources

• LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
• Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
• LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
• HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith

References

1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).

2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)

3. Pediatrics. 2013 Jul;132(1):198-203.

4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)

5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.

Transgender and gender-expansive youth face many barriers to health care. (Gender-expansive youth are defined as “youth who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience.”) Although some of these youth may be fortunate to have a supportive family and access to health care providers proficient in transgender health care, they still face difficulties in having their insurance cover transgender-related services. This is not an impossible task, but it is a constant struggle for many clinicians.

In this column, I will provide some tips and strategies to help clinicians get insurance companies to cover these critical services. However, keep in mind that there is no one-size-fits-all approach to obtaining insurance coverage. In addition, growing uncertainty over the repeal of the Affordable Care Act (ACA) – which was critical in lifting many of the barriers to insurance coverage for transgender individuals – will make this task challenging.

Health insurance is extraordinarily complex. There are multiple private and public plans that vary in the services they cover. This variation is state dependent. And even within states, there is additional variability. Most health insurance plans are purchased by employers, and employers have a choice of what can be covered in their health plans. So even though an insurance company may state that it covers transgender-related services, the patient’s employer may pay for a plan that doesn’t cover such services. The only way to be sure whether a patient’s insurance will cover transgender-related services or not is to contact the insurance provider directly, but with extremely busy schedules and heavy patient loads, this is easier said than done. It would be helpful to have a social worker perform this task, but even having a social worker can be a luxury for some clinics.

copyright teekid/iStockphoto

copyright Hlib Shabashnyi/Thinkstock

1.  Patient’s identifying information. Usually the patient’s name and date of birth is sufficient. Clinicians should use the patient’s preferred name in the letter, but provide the insurance or legal name of the patient so that the insurance provider can locate the patient’s records.

2.  Result of a psychosocial evaluation and diagnosis (if any). Many insurance providers are looking specifically for the gender dysphoria diagnosis.

3.  The duration of the referring health professional’s relationship with the patient, which includes the type of evaluation and therapy or counseling (e.g., cognitive behavior therapy or gender coaching).

4.  An explanation that the criteria (usually from the World Professional Association for Transgender Health standard of care⁴ or the Endocrine Society Guidelines titled Endocrine Treatment of Transsexual Persons⁵) for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy.

5.  A statement that informed consent has been obtained from the patient (or parental permission if the patient is younger than 18 years).

6.  A statement that the referring health professional is available for coordination of care.

If the clinician fails to convince the insurance provider of the necessity of covering transgender-related services, the patient still can pay out of pocket. Some hormones can be affordable to certain patients. In the state of Pennsylvania, for example, a 10-mL vial of testosterone can cost anywhere from $60 to $80, and may generally last anywhere from 10 weeks to a year, depending on dosage. Nevertheless, these costs still may be prohibitive for many transgender youth. Many are chronically unemployed or underemployed, or struggle with homelessness.⁶ Some transgender youth have to the face the excruciatingly difficult choice between having something to eat for the day or living another day with gender dysphoria.

Clinicians should work very hard to make sure that their transgender and gender-expansive patients obtain the care they need. The above strategies may help navigate the complex insurance system. However, insurance policies vary by state, and anti-trans discrimination creates additional barriers to health care. Therefore, clinicians who take care of transgender youth also should advocate for policies that protect these patients from discrimination, and they should advocate for policies that expand medical coverage for this vulnerable population.
 

Resources

•  The Human Rights Campaign keeps a list of insurance plans that cover transgender-related services, but this list is far from comprehensive.

•  Healthcare.gov provides some guidance on how to obtain coverage and navigate the insurance system for transgender individuals.

•  UCSF Center of Excellence for Transgender Health provides some excellent resources and guidance on obtaining insurance coverage for transgender individuals.

References

1.   LGBT Health 2014;1(4):256-8.

2.   Map: State Health Insurance Rules: National Center for Transgender Equality, 2016 [Available from: www.transequality.org/issues/resources/map-state-health-insurance-rules].

3.   Health insurance coverage issues for transgender people in the United States: University of California, San Fransisco Center of Excellence for Transgender Health, 2017 [Available from: http://transhealth.ucsf.edu/trans?page=guidelines-insurance].

4.   International Journal of Transgenderism 2012;13(4):165-232.

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

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

Transgender and gender-expansive youth face many barriers to health care. (Gender-expansive youth are defined as “youth who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience.”) Although some of these youth may be fortunate to have a supportive family and access to health care providers proficient in transgender health care, they still face difficulties in having their insurance cover transgender-related services. This is not an impossible task, but it is a constant struggle for many clinicians.

In this column, I will provide some tips and strategies to help clinicians get insurance companies to cover these critical services. However, keep in mind that there is no one-size-fits-all approach to obtaining insurance coverage. In addition, growing uncertainty over the repeal of the Affordable Care Act (ACA) – which was critical in lifting many of the barriers to insurance coverage for transgender individuals – will make this task challenging.

Health insurance is extraordinarily complex. There are multiple private and public plans that vary in the services they cover. This variation is state dependent. And even within states, there is additional variability. Most health insurance plans are purchased by employers, and employers have a choice of what can be covered in their health plans. So even though an insurance company may state that it covers transgender-related services, the patient’s employer may pay for a plan that doesn’t cover such services. The only way to be sure whether a patient’s insurance will cover transgender-related services or not is to contact the insurance provider directly, but with extremely busy schedules and heavy patient loads, this is easier said than done. It would be helpful to have a social worker perform this task, but even having a social worker can be a luxury for some clinics.

copyright teekid/iStockphoto

copyright Hlib Shabashnyi/Thinkstock

1.  Patient’s identifying information. Usually the patient’s name and date of birth is sufficient. Clinicians should use the patient’s preferred name in the letter, but provide the insurance or legal name of the patient so that the insurance provider can locate the patient’s records.

2.  Result of a psychosocial evaluation and diagnosis (if any). Many insurance providers are looking specifically for the gender dysphoria diagnosis.

3.  The duration of the referring health professional’s relationship with the patient, which includes the type of evaluation and therapy or counseling (e.g., cognitive behavior therapy or gender coaching).

4.  An explanation that the criteria (usually from the World Professional Association for Transgender Health standard of care⁴ or the Endocrine Society Guidelines titled Endocrine Treatment of Transsexual Persons⁵) for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy.

5.  A statement that informed consent has been obtained from the patient (or parental permission if the patient is younger than 18 years).

6.  A statement that the referring health professional is available for coordination of care.

If the clinician fails to convince the insurance provider of the necessity of covering transgender-related services, the patient still can pay out of pocket. Some hormones can be affordable to certain patients. In the state of Pennsylvania, for example, a 10-mL vial of testosterone can cost anywhere from $60 to $80, and may generally last anywhere from 10 weeks to a year, depending on dosage. Nevertheless, these costs still may be prohibitive for many transgender youth. Many are chronically unemployed or underemployed, or struggle with homelessness.⁶ Some transgender youth have to the face the excruciatingly difficult choice between having something to eat for the day or living another day with gender dysphoria.

Clinicians should work very hard to make sure that their transgender and gender-expansive patients obtain the care they need. The above strategies may help navigate the complex insurance system. However, insurance policies vary by state, and anti-trans discrimination creates additional barriers to health care. Therefore, clinicians who take care of transgender youth also should advocate for policies that protect these patients from discrimination, and they should advocate for policies that expand medical coverage for this vulnerable population.
 

Resources

•  The Human Rights Campaign keeps a list of insurance plans that cover transgender-related services, but this list is far from comprehensive.

•  Healthcare.gov provides some guidance on how to obtain coverage and navigate the insurance system for transgender individuals.

•  UCSF Center of Excellence for Transgender Health provides some excellent resources and guidance on obtaining insurance coverage for transgender individuals.

References

1.   LGBT Health 2014;1(4):256-8.

2.   Map: State Health Insurance Rules: National Center for Transgender Equality, 2016 [Available from: www.transequality.org/issues/resources/map-state-health-insurance-rules].

3.   Health insurance coverage issues for transgender people in the United States: University of California, San Fransisco Center of Excellence for Transgender Health, 2017 [Available from: http://transhealth.ucsf.edu/trans?page=guidelines-insurance].

4.   International Journal of Transgenderism 2012;13(4):165-232.

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

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

Transgender and gender-expansive youth face many barriers to health care. (Gender-expansive youth are defined as “youth who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience.”) Although some of these youth may be fortunate to have a supportive family and access to health care providers proficient in transgender health care, they still face difficulties in having their insurance cover transgender-related services. This is not an impossible task, but it is a constant struggle for many clinicians.

In this column, I will provide some tips and strategies to help clinicians get insurance companies to cover these critical services. However, keep in mind that there is no one-size-fits-all approach to obtaining insurance coverage. In addition, growing uncertainty over the repeal of the Affordable Care Act (ACA) – which was critical in lifting many of the barriers to insurance coverage for transgender individuals – will make this task challenging.

Health insurance is extraordinarily complex. There are multiple private and public plans that vary in the services they cover. This variation is state dependent. And even within states, there is additional variability. Most health insurance plans are purchased by employers, and employers have a choice of what can be covered in their health plans. So even though an insurance company may state that it covers transgender-related services, the patient’s employer may pay for a plan that doesn’t cover such services. The only way to be sure whether a patient’s insurance will cover transgender-related services or not is to contact the insurance provider directly, but with extremely busy schedules and heavy patient loads, this is easier said than done. It would be helpful to have a social worker perform this task, but even having a social worker can be a luxury for some clinics.

copyright teekid/iStockphoto

copyright Hlib Shabashnyi/Thinkstock

1.  Patient’s identifying information. Usually the patient’s name and date of birth is sufficient. Clinicians should use the patient’s preferred name in the letter, but provide the insurance or legal name of the patient so that the insurance provider can locate the patient’s records.

2.  Result of a psychosocial evaluation and diagnosis (if any). Many insurance providers are looking specifically for the gender dysphoria diagnosis.

3.  The duration of the referring health professional’s relationship with the patient, which includes the type of evaluation and therapy or counseling (e.g., cognitive behavior therapy or gender coaching).

4.  An explanation that the criteria (usually from the World Professional Association for Transgender Health standard of care⁴ or the Endocrine Society Guidelines titled Endocrine Treatment of Transsexual Persons⁵) for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy.

5.  A statement that informed consent has been obtained from the patient (or parental permission if the patient is younger than 18 years).

6.  A statement that the referring health professional is available for coordination of care.

If the clinician fails to convince the insurance provider of the necessity of covering transgender-related services, the patient still can pay out of pocket. Some hormones can be affordable to certain patients. In the state of Pennsylvania, for example, a 10-mL vial of testosterone can cost anywhere from $60 to $80, and may generally last anywhere from 10 weeks to a year, depending on dosage. Nevertheless, these costs still may be prohibitive for many transgender youth. Many are chronically unemployed or underemployed, or struggle with homelessness.⁶ Some transgender youth have to the face the excruciatingly difficult choice between having something to eat for the day or living another day with gender dysphoria.

Clinicians should work very hard to make sure that their transgender and gender-expansive patients obtain the care they need. The above strategies may help navigate the complex insurance system. However, insurance policies vary by state, and anti-trans discrimination creates additional barriers to health care. Therefore, clinicians who take care of transgender youth also should advocate for policies that protect these patients from discrimination, and they should advocate for policies that expand medical coverage for this vulnerable population.
 

Resources

•  The Human Rights Campaign keeps a list of insurance plans that cover transgender-related services, but this list is far from comprehensive.

•  Healthcare.gov provides some guidance on how to obtain coverage and navigate the insurance system for transgender individuals.

•  UCSF Center of Excellence for Transgender Health provides some excellent resources and guidance on obtaining insurance coverage for transgender individuals.

References

1.   LGBT Health 2014;1(4):256-8.

2.   Map: State Health Insurance Rules: National Center for Transgender Equality, 2016 [Available from: www.transequality.org/issues/resources/map-state-health-insurance-rules].

3.   Health insurance coverage issues for transgender people in the United States: University of California, San Fransisco Center of Excellence for Transgender Health, 2017 [Available from: http://transhealth.ucsf.edu/trans?page=guidelines-insurance].

4.   International Journal of Transgenderism 2012;13(4):165-232.

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

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

Adolescence is a time of rapid growth and development both physically and emotionally. Some of the major tasks of adolescent development include developing a stable identity (this includes sexual and gender identity) and establishing independence from parents. This separation process from parents is often buffered by peer relationships. By the end of adolescence, those who are healthy and mature in their sexuality are able to:^1,2,3

•  Identify and live according to their own values and take responsibility for their behavior.

•  Practice effective decision-making, and develop critical-thinking skills.

•  Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.

•  Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.

•  Interact with all genders in respectful and appropriate ways.

•  Affirm their own gender identity and sexual orientation, and respect the gender identities and sexual orientations of others.

•  Appreciate their body and enjoy their sexuality throughout life, expressing sexuality in ways that are congruent with their values.

•  Express love and intimacy in appropriate ways.

•  Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.

•  Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.

Anywhere from 5% to 10% of teens identify as lesbian, gay, or bisexual (LGB).⁴ For these teens, the development of a sexual identity can add additional challenges to the development process, particularly if youth do not feel supported by family, peers, and their communities. Previous columns have addressed the role family acceptance can play in promoting the healthy development of sexual minority youth. Likewise, peer relationships also can play an important role in an adolescent’s development and health.

•  Acceptance.

•  Competence.

•  Higher levels of self-esteem and psychological well-being.

•  Strong sense of self and self-acceptance.

•  Strong ethnic identification.

•  Strong connections to family and school.

•  Caring adult role models outside the family.

•  Community involvement.

For some youth who may not be able receive acceptance from their families, peers and trusted adults may fill in this role and serve as a “chosen family.” A chosen family is commonly understood to mean a group of people who deliberately chose one another to play significant roles in each other’s lives even though they are not biologically or legally related. These relationships may be in addition to or in place of traditional family relationships. These connections can increase a youth’s sense of acceptance and connectedness and help promote resiliency.

Adolescents often may struggle on the decision of when to “come out” or disclose their sexual orientation to friends and family, and may ask their health care providers for advice. The number one consideration when making a decision about disclosure is safety. Unfortunately, some family members and peers may not react in a supportive manner to a youth’s disclosure, and disclosure may result in being kicked out, financial coercion, bullying, physical violence, or alienation. In these cases, youth may choose to delay disclosure until they are in a more supportive environment, and health care providers can play an important role in validating and affirming patients’ identities and maintaining confidentiality as appropriate. LGB youth should be counseled to consider the when, who, and how of their disclosure. They also should plan for how they might deal with a negative or rejecting response. Some tips are included below.⁵

When

•  You are ready.

•  You are comfortable with your identity.

•  You want to share information with people you trust and are close to.

•  You have a plan for support if you are not accepted (particularly when coming out to family).

Who

•  Someone you know well and expect to be supportive.

•  Someone you trust, feel safe with, and who can keep information confidential if needed (may need to explore school’s privacy and confidentiality policies if disclosing to a teacher or school personnel).

•  Be clear about who else information may be shared with and who NOT to share with.

How

•  Be sure you are prepared. You may want to talk to other sexual minority youth or adults who have come out, attend LGBTQ groups/forums, or seek out Internet resources to learn about others’ coming out experiences. These sources may serve as a support for you should you experience any negative or rejecting responses.

•  Make sure you have support resources in place prior to coming out.

•  Coming out by letter allows you time to carefully word what you want to say, and allows the other person time and privacy to consider their response.

•  If coming out in person, try to choose a quiet private space, and try to choose a time when everyone is relaxed and well-rested.

•  If concerned about your safety, make sure other people are immediately accessible if needed.

•  Plan what you are going to say, how you might end the conversation, and how you may want to talk about it later.

•  Listen actively to what the other person has to say.

•  Avoid any alcohol or drugs, as these may affect your mental and emotional state and responses.

•  Avoid coming out because of pressure from others or because you are angry.

Youth should be reminded that people’s responses may not always be predictable. It is important to note that for many individuals, coming out may be a lifelong process and occur in stages, beginning with close friends or family members and progressing from there. In the age of social media, youth should be reminded that disclosures through social media may be widely accessible, are easily shared, and may be difficult to remove. For youth who do not have supportive peer groups, and may not be able to disclose their sexual identity, providing support resources can be helpful.
 

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Resources for sexual minority youth and peers/families

Gay-Straight Alliance Network: gsanetwork.org

Gay Lesbian Straight Education Network: Information for Students: glsen.org/students

Sexuality Information and Education Council of the United States: www.siecus.org

The Trevor Project: Help and Suicide Prevention: www.thetrevorproject.org

It Gets Better Project: http://www.itgetsbetter.org/

Family and Ally Organization: PFLAG: https://www.pflag.org/

Advocates for Youth Parent Tips: http://www.advocatesforyouth.org/parents/173-parents

References

1. “Adolescent Sexuality,” by Michelle Forcier, MD, in Up to Date. Updated March 2017.

2. Pediatrics. 2016 Aug;138(2). pii: e20161348.

3. The Guidelines for Comprehensive Sexuality Education: Grades K-12 (Washington, D.C.: Sexuality Information and Education Council of the United States, 2004).

4. MMWR Surveillance Summaries, 2016, Aug 12;65(9):1-202.

5. “Sexual minority youth: Epidemiology and health concerns,” by Michelle Forcier, MD, and Johanna Olson-Kennedy, MD, in Up to Date.
 

Adolescence is a time of rapid growth and development both physically and emotionally. Some of the major tasks of adolescent development include developing a stable identity (this includes sexual and gender identity) and establishing independence from parents. This separation process from parents is often buffered by peer relationships. By the end of adolescence, those who are healthy and mature in their sexuality are able to:^1,2,3

•  Identify and live according to their own values and take responsibility for their behavior.

•  Practice effective decision-making, and develop critical-thinking skills.

•  Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.

•  Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.

•  Interact with all genders in respectful and appropriate ways.

•  Affirm their own gender identity and sexual orientation, and respect the gender identities and sexual orientations of others.

•  Appreciate their body and enjoy their sexuality throughout life, expressing sexuality in ways that are congruent with their values.

•  Express love and intimacy in appropriate ways.

•  Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.

•  Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.

Anywhere from 5% to 10% of teens identify as lesbian, gay, or bisexual (LGB).⁴ For these teens, the development of a sexual identity can add additional challenges to the development process, particularly if youth do not feel supported by family, peers, and their communities. Previous columns have addressed the role family acceptance can play in promoting the healthy development of sexual minority youth. Likewise, peer relationships also can play an important role in an adolescent’s development and health.

•  Acceptance.

•  Competence.

•  Higher levels of self-esteem and psychological well-being.

•  Strong sense of self and self-acceptance.

•  Strong ethnic identification.

•  Strong connections to family and school.

•  Caring adult role models outside the family.

•  Community involvement.

For some youth who may not be able receive acceptance from their families, peers and trusted adults may fill in this role and serve as a “chosen family.” A chosen family is commonly understood to mean a group of people who deliberately chose one another to play significant roles in each other’s lives even though they are not biologically or legally related. These relationships may be in addition to or in place of traditional family relationships. These connections can increase a youth’s sense of acceptance and connectedness and help promote resiliency.

Adolescents often may struggle on the decision of when to “come out” or disclose their sexual orientation to friends and family, and may ask their health care providers for advice. The number one consideration when making a decision about disclosure is safety. Unfortunately, some family members and peers may not react in a supportive manner to a youth’s disclosure, and disclosure may result in being kicked out, financial coercion, bullying, physical violence, or alienation. In these cases, youth may choose to delay disclosure until they are in a more supportive environment, and health care providers can play an important role in validating and affirming patients’ identities and maintaining confidentiality as appropriate. LGB youth should be counseled to consider the when, who, and how of their disclosure. They also should plan for how they might deal with a negative or rejecting response. Some tips are included below.⁵

When

•  You are ready.

•  You are comfortable with your identity.

•  You want to share information with people you trust and are close to.

•  You have a plan for support if you are not accepted (particularly when coming out to family).

Who

•  Someone you know well and expect to be supportive.

•  Someone you trust, feel safe with, and who can keep information confidential if needed (may need to explore school’s privacy and confidentiality policies if disclosing to a teacher or school personnel).

•  Be clear about who else information may be shared with and who NOT to share with.

How

•  Be sure you are prepared. You may want to talk to other sexual minority youth or adults who have come out, attend LGBTQ groups/forums, or seek out Internet resources to learn about others’ coming out experiences. These sources may serve as a support for you should you experience any negative or rejecting responses.

•  Make sure you have support resources in place prior to coming out.

•  Coming out by letter allows you time to carefully word what you want to say, and allows the other person time and privacy to consider their response.

•  If coming out in person, try to choose a quiet private space, and try to choose a time when everyone is relaxed and well-rested.

•  If concerned about your safety, make sure other people are immediately accessible if needed.

•  Plan what you are going to say, how you might end the conversation, and how you may want to talk about it later.

•  Listen actively to what the other person has to say.

•  Avoid any alcohol or drugs, as these may affect your mental and emotional state and responses.

•  Avoid coming out because of pressure from others or because you are angry.

Youth should be reminded that people’s responses may not always be predictable. It is important to note that for many individuals, coming out may be a lifelong process and occur in stages, beginning with close friends or family members and progressing from there. In the age of social media, youth should be reminded that disclosures through social media may be widely accessible, are easily shared, and may be difficult to remove. For youth who do not have supportive peer groups, and may not be able to disclose their sexual identity, providing support resources can be helpful.
 

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Resources for sexual minority youth and peers/families

Gay-Straight Alliance Network: gsanetwork.org

Gay Lesbian Straight Education Network: Information for Students: glsen.org/students

Sexuality Information and Education Council of the United States: www.siecus.org

The Trevor Project: Help and Suicide Prevention: www.thetrevorproject.org

It Gets Better Project: http://www.itgetsbetter.org/

Family and Ally Organization: PFLAG: https://www.pflag.org/

Advocates for Youth Parent Tips: http://www.advocatesforyouth.org/parents/173-parents

References

1. “Adolescent Sexuality,” by Michelle Forcier, MD, in Up to Date. Updated March 2017.

2. Pediatrics. 2016 Aug;138(2). pii: e20161348.

3. The Guidelines for Comprehensive Sexuality Education: Grades K-12 (Washington, D.C.: Sexuality Information and Education Council of the United States, 2004).

4. MMWR Surveillance Summaries, 2016, Aug 12;65(9):1-202.

5. “Sexual minority youth: Epidemiology and health concerns,” by Michelle Forcier, MD, and Johanna Olson-Kennedy, MD, in Up to Date.
 

Adolescence is a time of rapid growth and development both physically and emotionally. Some of the major tasks of adolescent development include developing a stable identity (this includes sexual and gender identity) and establishing independence from parents. This separation process from parents is often buffered by peer relationships. By the end of adolescence, those who are healthy and mature in their sexuality are able to:^1,2,3

•  Identify and live according to their own values and take responsibility for their behavior.

•  Practice effective decision-making, and develop critical-thinking skills.

•  Affirm that human development includes sexual development, which may or may not include reproduction or sexual experience.

•  Seek further information about sexuality and reproduction as needed and make informed choices about family options and relationships.

•  Interact with all genders in respectful and appropriate ways.

•  Affirm their own gender identity and sexual orientation, and respect the gender identities and sexual orientations of others.

•  Appreciate their body and enjoy their sexuality throughout life, expressing sexuality in ways that are congruent with their values.

•  Express love and intimacy in appropriate ways.

•  Develop and maintain meaningful relationships, avoiding exploitative or manipulative relationships.

•  Exhibit skills and communication that enhance personal relationships with family, peers, and romantic partners.

Anywhere from 5% to 10% of teens identify as lesbian, gay, or bisexual (LGB).⁴ For these teens, the development of a sexual identity can add additional challenges to the development process, particularly if youth do not feel supported by family, peers, and their communities. Previous columns have addressed the role family acceptance can play in promoting the healthy development of sexual minority youth. Likewise, peer relationships also can play an important role in an adolescent’s development and health.

•  Acceptance.

•  Competence.

•  Higher levels of self-esteem and psychological well-being.

•  Strong sense of self and self-acceptance.

•  Strong ethnic identification.

•  Strong connections to family and school.

•  Caring adult role models outside the family.

•  Community involvement.

For some youth who may not be able receive acceptance from their families, peers and trusted adults may fill in this role and serve as a “chosen family.” A chosen family is commonly understood to mean a group of people who deliberately chose one another to play significant roles in each other’s lives even though they are not biologically or legally related. These relationships may be in addition to or in place of traditional family relationships. These connections can increase a youth’s sense of acceptance and connectedness and help promote resiliency.

Adolescents often may struggle on the decision of when to “come out” or disclose their sexual orientation to friends and family, and may ask their health care providers for advice. The number one consideration when making a decision about disclosure is safety. Unfortunately, some family members and peers may not react in a supportive manner to a youth’s disclosure, and disclosure may result in being kicked out, financial coercion, bullying, physical violence, or alienation. In these cases, youth may choose to delay disclosure until they are in a more supportive environment, and health care providers can play an important role in validating and affirming patients’ identities and maintaining confidentiality as appropriate. LGB youth should be counseled to consider the when, who, and how of their disclosure. They also should plan for how they might deal with a negative or rejecting response. Some tips are included below.⁵

When

•  You are ready.

•  You are comfortable with your identity.

•  You want to share information with people you trust and are close to.

•  You have a plan for support if you are not accepted (particularly when coming out to family).

Who

•  Someone you know well and expect to be supportive.

•  Someone you trust, feel safe with, and who can keep information confidential if needed (may need to explore school’s privacy and confidentiality policies if disclosing to a teacher or school personnel).

•  Be clear about who else information may be shared with and who NOT to share with.

How

•  Be sure you are prepared. You may want to talk to other sexual minority youth or adults who have come out, attend LGBTQ groups/forums, or seek out Internet resources to learn about others’ coming out experiences. These sources may serve as a support for you should you experience any negative or rejecting responses.

•  Make sure you have support resources in place prior to coming out.

•  Coming out by letter allows you time to carefully word what you want to say, and allows the other person time and privacy to consider their response.

•  If coming out in person, try to choose a quiet private space, and try to choose a time when everyone is relaxed and well-rested.

•  If concerned about your safety, make sure other people are immediately accessible if needed.

•  Plan what you are going to say, how you might end the conversation, and how you may want to talk about it later.

•  Listen actively to what the other person has to say.

•  Avoid any alcohol or drugs, as these may affect your mental and emotional state and responses.

•  Avoid coming out because of pressure from others or because you are angry.

Youth should be reminded that people’s responses may not always be predictable. It is important to note that for many individuals, coming out may be a lifelong process and occur in stages, beginning with close friends or family members and progressing from there. In the age of social media, youth should be reminded that disclosures through social media may be widely accessible, are easily shared, and may be difficult to remove. For youth who do not have supportive peer groups, and may not be able to disclose their sexual identity, providing support resources can be helpful.
 

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Resources for sexual minority youth and peers/families

Gay-Straight Alliance Network: gsanetwork.org

Gay Lesbian Straight Education Network: Information for Students: glsen.org/students

Sexuality Information and Education Council of the United States: www.siecus.org

The Trevor Project: Help and Suicide Prevention: www.thetrevorproject.org

It Gets Better Project: http://www.itgetsbetter.org/

Family and Ally Organization: PFLAG: https://www.pflag.org/

Advocates for Youth Parent Tips: http://www.advocatesforyouth.org/parents/173-parents

References

1. “Adolescent Sexuality,” by Michelle Forcier, MD, in Up to Date. Updated March 2017.

2. Pediatrics. 2016 Aug;138(2). pii: e20161348.

3. The Guidelines for Comprehensive Sexuality Education: Grades K-12 (Washington, D.C.: Sexuality Information and Education Council of the United States, 2004).

4. MMWR Surveillance Summaries, 2016, Aug 12;65(9):1-202.

5. “Sexual minority youth: Epidemiology and health concerns,” by Michelle Forcier, MD, and Johanna Olson-Kennedy, MD, in Up to Date.
 

Recently North Carolina proposed a bill (House Bill 780) that will ban same-sex marriage in the state, even though the U.S. Supreme Court ruled in 2015 that no states can ban same-sex marriage because doing so violates the 14th Amendment. Although many mainly will argue that H.B. 780 is unconstitutional, this bill also can be detrimental to the health of lesbian, gay, and bisexual (LGB) youth.

In March 2017, JAMA Pediatrics published a study on the association between same-sex marriage laws and the rates of suicide attempts.¹ Using data from the Youth Risk Behavior Surveillance System, they analyzed the relationship between state policies that permitted same-sex marriage and self-report of suicide attempts within the last 12 months. Thirty percent of LGB youth (13% of the survey population) reported a suicide attempt in the past year prior to any state policies that permitted same-sex marriage, compared with about 9% of the general population. After states implemented pro–same-sex marriage policies, LGB youth suicide attempts dropped to about 26% – a 14% relative decline. This was not limited to LGB youth. The general youth suicide rates declined from 8.6% to 8% – a 7% relative decline. Although the change in suicide attempts was small, the authors determined that the likelihood it occurred by chance was very slim, and concluded that policies enabling same-sex marriage may be associated with an improvement in population health, especially for LGB youth.

This was not the first study examining the relationship between policies and the health of LGB youth. Mark Hatzenbuehler, PhD, of Columbia University, New York, and his associates have published multiple studies on this topic. Four years earlier, Hatzenbuehler et al. published a study on the relationship between antibullying policies and suicide among LGB youth. Using data from the Oregon Healthy Teen survey (2006-2008), he found that LGB youth who live in counties where there are fewer districts with antibullying policies are more than twice as likely to attempt suicide, compared with LGB youth who live in counties where more districts had antibullying policies. Furthermore, the type of antibullying policy mattered. If a district’s antibullying policy did not prohibit bullying based on sexual orientation, then it had no impact on the suicide attempt rates of LGB youth in that area.² Similar results were found when the relationship between anti–homophobic bullying policies and LGB suicide attempts was examined in the larger Youth Risk Behavior Surveillance System.³

State and local policies also influence other health outcomes among LGB youth. Hatzenbuehler et al. did another study that examined community-level determinants of tobacco use among LGB youth. Again using the data from the Oregon Healthy Teen Survey, they found that LGB youth living in communities that were more supportive of LGB youth (i.e., communities with a high proportion of same-sex couples living in the area, a high proportion of gay-straight alliances at schools, and LGB-specific antibullying policies) were less likely to smoke cigarettes, compared with LGB youth living in communities that were less supportive.⁴ A similar study in Canada by Konishi et al. found that schools with gay-straight alliances and anti–homophobic bullying policies were less likely to have LGB youth engaging in risky alcohol or illicit drug use.⁵

Why do these policies matter? A common theme among these policies is that they can either cause or alleviate stress for LGB youth. States that restrict same-sex marriages or schools that do not have any gay-straight alliances may signal to LGB youth that they are not valued or welcomed, or at the very worse, are despised. This creates a hostile and stressful environment for LGB youth, which raises the risk for mental health problems, such as depression and anxiety, which in turn, raises the risk for substance use and suicide.⁶ Conversely, the presence of a gay-straight alliance at school or a state that allows same-sex marriage may indicate to LGB youth that they are welcomed, if not just tolerated, and may alleviate this risk. Furthermore, antibullying policies seem to reduce the stress associated with bullying among LGB youth because it may serve as a deterrent to bullying based on sexual orientation. Although passing pro-LGB policies will not solve all the health problems among LGB youth, these policies certainly have an impact.

There might be trepidation among some pediatricians about being vocal on a politically charged policy proposal such as H.B. 780. However, suicide and substance use are major concerns for all physicians – especially pediatricians. Policy makers considering passing laws that can affect their LGB constituents should read these studies to see what kind of influence these proposals can have on the health and well-being of LGB youth. Moreover, health care providers should use their expertise, influence, and standing in their community to support policies that encourage protection for LGB youth and oppose policies that can harm LGB youth. These leaders are responsible for ensuring the health of the people they serve.
 

Dr. Montano is clinical instructor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC.

References

1. JAMA Pediatr. 2017. doi: 10.1001/jamapediatrics.2016.4529.

2. J Adolesc Health. 2013:S21-6. doi: 10.1016/j.jadohealth.2012.08.010.

3. Am J Public Health. 2014. doi: 10.2105/AJPH.2013.301508.

4. Arch Pediatr Adolesc Med. 2011. doi: 10.1001/archpediatrics.2011.64.

5. Prev Med. 2013. doi: 10.1016/j.ypmed.2013.06.031.

6. Psychol Bull. 2003. doi: 10.1037/0033-2909.129.5.674.

Recently North Carolina proposed a bill (House Bill 780) that will ban same-sex marriage in the state, even though the U.S. Supreme Court ruled in 2015 that no states can ban same-sex marriage because doing so violates the 14th Amendment. Although many mainly will argue that H.B. 780 is unconstitutional, this bill also can be detrimental to the health of lesbian, gay, and bisexual (LGB) youth.

In March 2017, JAMA Pediatrics published a study on the association between same-sex marriage laws and the rates of suicide attempts.¹ Using data from the Youth Risk Behavior Surveillance System, they analyzed the relationship between state policies that permitted same-sex marriage and self-report of suicide attempts within the last 12 months. Thirty percent of LGB youth (13% of the survey population) reported a suicide attempt in the past year prior to any state policies that permitted same-sex marriage, compared with about 9% of the general population. After states implemented pro–same-sex marriage policies, LGB youth suicide attempts dropped to about 26% – a 14% relative decline. This was not limited to LGB youth. The general youth suicide rates declined from 8.6% to 8% – a 7% relative decline. Although the change in suicide attempts was small, the authors determined that the likelihood it occurred by chance was very slim, and concluded that policies enabling same-sex marriage may be associated with an improvement in population health, especially for LGB youth.

This was not the first study examining the relationship between policies and the health of LGB youth. Mark Hatzenbuehler, PhD, of Columbia University, New York, and his associates have published multiple studies on this topic. Four years earlier, Hatzenbuehler et al. published a study on the relationship between antibullying policies and suicide among LGB youth. Using data from the Oregon Healthy Teen survey (2006-2008), he found that LGB youth who live in counties where there are fewer districts with antibullying policies are more than twice as likely to attempt suicide, compared with LGB youth who live in counties where more districts had antibullying policies. Furthermore, the type of antibullying policy mattered. If a district’s antibullying policy did not prohibit bullying based on sexual orientation, then it had no impact on the suicide attempt rates of LGB youth in that area.² Similar results were found when the relationship between anti–homophobic bullying policies and LGB suicide attempts was examined in the larger Youth Risk Behavior Surveillance System.³

State and local policies also influence other health outcomes among LGB youth. Hatzenbuehler et al. did another study that examined community-level determinants of tobacco use among LGB youth. Again using the data from the Oregon Healthy Teen Survey, they found that LGB youth living in communities that were more supportive of LGB youth (i.e., communities with a high proportion of same-sex couples living in the area, a high proportion of gay-straight alliances at schools, and LGB-specific antibullying policies) were less likely to smoke cigarettes, compared with LGB youth living in communities that were less supportive.⁴ A similar study in Canada by Konishi et al. found that schools with gay-straight alliances and anti–homophobic bullying policies were less likely to have LGB youth engaging in risky alcohol or illicit drug use.⁵

Why do these policies matter? A common theme among these policies is that they can either cause or alleviate stress for LGB youth. States that restrict same-sex marriages or schools that do not have any gay-straight alliances may signal to LGB youth that they are not valued or welcomed, or at the very worse, are despised. This creates a hostile and stressful environment for LGB youth, which raises the risk for mental health problems, such as depression and anxiety, which in turn, raises the risk for substance use and suicide.⁶ Conversely, the presence of a gay-straight alliance at school or a state that allows same-sex marriage may indicate to LGB youth that they are welcomed, if not just tolerated, and may alleviate this risk. Furthermore, antibullying policies seem to reduce the stress associated with bullying among LGB youth because it may serve as a deterrent to bullying based on sexual orientation. Although passing pro-LGB policies will not solve all the health problems among LGB youth, these policies certainly have an impact.

There might be trepidation among some pediatricians about being vocal on a politically charged policy proposal such as H.B. 780. However, suicide and substance use are major concerns for all physicians – especially pediatricians. Policy makers considering passing laws that can affect their LGB constituents should read these studies to see what kind of influence these proposals can have on the health and well-being of LGB youth. Moreover, health care providers should use their expertise, influence, and standing in their community to support policies that encourage protection for LGB youth and oppose policies that can harm LGB youth. These leaders are responsible for ensuring the health of the people they serve.
 

Dr. Montano is clinical instructor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC.

References

1. JAMA Pediatr. 2017. doi: 10.1001/jamapediatrics.2016.4529.

2. J Adolesc Health. 2013:S21-6. doi: 10.1016/j.jadohealth.2012.08.010.

3. Am J Public Health. 2014. doi: 10.2105/AJPH.2013.301508.

4. Arch Pediatr Adolesc Med. 2011. doi: 10.1001/archpediatrics.2011.64.

5. Prev Med. 2013. doi: 10.1016/j.ypmed.2013.06.031.

6. Psychol Bull. 2003. doi: 10.1037/0033-2909.129.5.674.

Recently North Carolina proposed a bill (House Bill 780) that will ban same-sex marriage in the state, even though the U.S. Supreme Court ruled in 2015 that no states can ban same-sex marriage because doing so violates the 14th Amendment. Although many mainly will argue that H.B. 780 is unconstitutional, this bill also can be detrimental to the health of lesbian, gay, and bisexual (LGB) youth.

In March 2017, JAMA Pediatrics published a study on the association between same-sex marriage laws and the rates of suicide attempts.¹ Using data from the Youth Risk Behavior Surveillance System, they analyzed the relationship between state policies that permitted same-sex marriage and self-report of suicide attempts within the last 12 months. Thirty percent of LGB youth (13% of the survey population) reported a suicide attempt in the past year prior to any state policies that permitted same-sex marriage, compared with about 9% of the general population. After states implemented pro–same-sex marriage policies, LGB youth suicide attempts dropped to about 26% – a 14% relative decline. This was not limited to LGB youth. The general youth suicide rates declined from 8.6% to 8% – a 7% relative decline. Although the change in suicide attempts was small, the authors determined that the likelihood it occurred by chance was very slim, and concluded that policies enabling same-sex marriage may be associated with an improvement in population health, especially for LGB youth.

This was not the first study examining the relationship between policies and the health of LGB youth. Mark Hatzenbuehler, PhD, of Columbia University, New York, and his associates have published multiple studies on this topic. Four years earlier, Hatzenbuehler et al. published a study on the relationship between antibullying policies and suicide among LGB youth. Using data from the Oregon Healthy Teen survey (2006-2008), he found that LGB youth who live in counties where there are fewer districts with antibullying policies are more than twice as likely to attempt suicide, compared with LGB youth who live in counties where more districts had antibullying policies. Furthermore, the type of antibullying policy mattered. If a district’s antibullying policy did not prohibit bullying based on sexual orientation, then it had no impact on the suicide attempt rates of LGB youth in that area.² Similar results were found when the relationship between anti–homophobic bullying policies and LGB suicide attempts was examined in the larger Youth Risk Behavior Surveillance System.³

State and local policies also influence other health outcomes among LGB youth. Hatzenbuehler et al. did another study that examined community-level determinants of tobacco use among LGB youth. Again using the data from the Oregon Healthy Teen Survey, they found that LGB youth living in communities that were more supportive of LGB youth (i.e., communities with a high proportion of same-sex couples living in the area, a high proportion of gay-straight alliances at schools, and LGB-specific antibullying policies) were less likely to smoke cigarettes, compared with LGB youth living in communities that were less supportive.⁴ A similar study in Canada by Konishi et al. found that schools with gay-straight alliances and anti–homophobic bullying policies were less likely to have LGB youth engaging in risky alcohol or illicit drug use.⁵

Why do these policies matter? A common theme among these policies is that they can either cause or alleviate stress for LGB youth. States that restrict same-sex marriages or schools that do not have any gay-straight alliances may signal to LGB youth that they are not valued or welcomed, or at the very worse, are despised. This creates a hostile and stressful environment for LGB youth, which raises the risk for mental health problems, such as depression and anxiety, which in turn, raises the risk for substance use and suicide.⁶ Conversely, the presence of a gay-straight alliance at school or a state that allows same-sex marriage may indicate to LGB youth that they are welcomed, if not just tolerated, and may alleviate this risk. Furthermore, antibullying policies seem to reduce the stress associated with bullying among LGB youth because it may serve as a deterrent to bullying based on sexual orientation. Although passing pro-LGB policies will not solve all the health problems among LGB youth, these policies certainly have an impact.

There might be trepidation among some pediatricians about being vocal on a politically charged policy proposal such as H.B. 780. However, suicide and substance use are major concerns for all physicians – especially pediatricians. Policy makers considering passing laws that can affect their LGB constituents should read these studies to see what kind of influence these proposals can have on the health and well-being of LGB youth. Moreover, health care providers should use their expertise, influence, and standing in their community to support policies that encourage protection for LGB youth and oppose policies that can harm LGB youth. These leaders are responsible for ensuring the health of the people they serve.
 

Dr. Montano is clinical instructor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC.

References

1. JAMA Pediatr. 2017. doi: 10.1001/jamapediatrics.2016.4529.

2. J Adolesc Health. 2013:S21-6. doi: 10.1016/j.jadohealth.2012.08.010.

3. Am J Public Health. 2014. doi: 10.2105/AJPH.2013.301508.

4. Arch Pediatr Adolesc Med. 2011. doi: 10.1001/archpediatrics.2011.64.

5. Prev Med. 2013. doi: 10.1016/j.ypmed.2013.06.031.

6. Psychol Bull. 2003. doi: 10.1037/0033-2909.129.5.674.

Lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ) youth face bias and discrimination within the health care setting and experience disparities in health, compared with their heterosexual cisgender peers. This is an area that is receiving increasing attention and study as health care providers and researchers work to achieve health equity within these populations.

Studies focusing specifically on the health of bisexual youth and adults are lacking. The few that do exist suggest that the experiences of people who identify as bisexual may be different from those who identify as lesbian or gay. Myths and misconceptions about bisexual, pansexual, queer, and fluid identities may in some cases put these populations at increased risks. Common myths include that bisexuality is just a phase or that youth who identify as bisexual are just confused. Studies suggest that bisexual youth account for almost half of youth who identify as LGBTQ. Understanding more about some of the challenges bisexual youth and adults may face can help us better care for all of our patients and families.

• Bisexual adults are more likely to engage in self-harming behaviors, attempt suicide, or think about suicide than heterosexual adults, lesbian women, or gay men.¹

• Bisexual women have higher rates of high blood pressure, compared with heterosexual and lesbian women.²

• Bisexual women have higher rates of alcohol-related disorders than lesbian and heterosexual women.¹

Some disparities appear to be related to lack of preventive care. A survey by the Williams Institute found that 39% of bisexual men and 33% of bisexual women did not disclose their sexual orientation, compared with 13% of gay men and 10% of lesbian women.¹ The effect of intersecting identities also must be considered when discussing these health disparities. More than 40% of LGBTQ people of color identify as bisexual, and almost half of transgender people describe their sexual orientation as bisexual or queer.¹ These individuals may be especially vulnerable to health disparities as they may experience a combination of racism, transphobia, and biphobia.

Risk factors for these disparities may develop early in life. A 2012 survey of LGBTQ youth found that:³

• Bisexual youth were less likely than lesbian and gay youth to report having supportive adults who they could turn to if they were sad.

• Only 5% of bisexual youth reported being very happy, compared with 8% of gay and lesbian youth and 21% of non-LGBT youth.

• Bisexual youth reported higher rates of experimentation with drugs and alcohol, compared with their lesbian, gay, and heterosexual peers.

• Bisexual youth reported lower levels of family acceptance and knowledge of social support systems in their communities than lesbian and gay youth. Both family acceptance and knowledge of social support systems have been identified as protective factors in the development of youth.

• Bisexual youth are less likely to be out to their friends, families, and communities.

As health care providers, recognizing, respecting, and supporting the identities of our bisexual patients is important. A few simple things we can do in practice are as follows:

• Don’t mislabel patients as lesbian, gay, or straight when they have disclosed a bisexual identity.

• Don’t assume that bisexuality is just a phase or that youths are confused when they disclose their identity.

• Don’t assume you know a patient’s sexual orientation or behaviors on the basis of the sex of the current partner or current behaviors.

• Do ask open and nonjudgmental questions about sexual attraction and behaviors, and be familiar with the terms bisexual, queer, questioning, and pansexual in addition to lesbian, gay, and straight.

• Do use inclusive terms like LGBT when referring to the community rather than gay rights.

• Do recognize potential biases and assumptions regarding sexuality and bisexuality and work to change them.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Terms and definitions:

Bisexual – A person who can be attracted to more than one sex, gender, or gender identity. “Bi” is often used as an abbreviation.

Biphobia – Prejudice, fear, or hatred directed toward bisexual people.

Queer – A term people often use to express fluid identities and orientations. Historically considered a pejorative term, but used by many youth to describe their identity.

Pansexual – A person who can be attracted to any sex, gender, or gender identity.

References:
 

1. ”Health Disparities Among Bisexual People,” brief by the Human Rights Campaign Foundation.

2. “New Mexico’s Progress in Collecting Lesbian, Gay, Bisexual, and Transgender Health Data and Its Implications for Addressing Health Disparities,” New Mexico Department of Health, April 2010.

3. “Supporting and Caring for Our Bisexual Youth,” the Human Rights Campaign Foundation, 2014.

Lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ) youth face bias and discrimination within the health care setting and experience disparities in health, compared with their heterosexual cisgender peers. This is an area that is receiving increasing attention and study as health care providers and researchers work to achieve health equity within these populations.

Studies focusing specifically on the health of bisexual youth and adults are lacking. The few that do exist suggest that the experiences of people who identify as bisexual may be different from those who identify as lesbian or gay. Myths and misconceptions about bisexual, pansexual, queer, and fluid identities may in some cases put these populations at increased risks. Common myths include that bisexuality is just a phase or that youth who identify as bisexual are just confused. Studies suggest that bisexual youth account for almost half of youth who identify as LGBTQ. Understanding more about some of the challenges bisexual youth and adults may face can help us better care for all of our patients and families.

• Bisexual adults are more likely to engage in self-harming behaviors, attempt suicide, or think about suicide than heterosexual adults, lesbian women, or gay men.¹

• Bisexual women have higher rates of high blood pressure, compared with heterosexual and lesbian women.²

• Bisexual women have higher rates of alcohol-related disorders than lesbian and heterosexual women.¹

Some disparities appear to be related to lack of preventive care. A survey by the Williams Institute found that 39% of bisexual men and 33% of bisexual women did not disclose their sexual orientation, compared with 13% of gay men and 10% of lesbian women.¹ The effect of intersecting identities also must be considered when discussing these health disparities. More than 40% of LGBTQ people of color identify as bisexual, and almost half of transgender people describe their sexual orientation as bisexual or queer.¹ These individuals may be especially vulnerable to health disparities as they may experience a combination of racism, transphobia, and biphobia.

Risk factors for these disparities may develop early in life. A 2012 survey of LGBTQ youth found that:³

• Bisexual youth were less likely than lesbian and gay youth to report having supportive adults who they could turn to if they were sad.

• Only 5% of bisexual youth reported being very happy, compared with 8% of gay and lesbian youth and 21% of non-LGBT youth.

• Bisexual youth reported higher rates of experimentation with drugs and alcohol, compared with their lesbian, gay, and heterosexual peers.

• Bisexual youth reported lower levels of family acceptance and knowledge of social support systems in their communities than lesbian and gay youth. Both family acceptance and knowledge of social support systems have been identified as protective factors in the development of youth.

• Bisexual youth are less likely to be out to their friends, families, and communities.

As health care providers, recognizing, respecting, and supporting the identities of our bisexual patients is important. A few simple things we can do in practice are as follows:

• Don’t mislabel patients as lesbian, gay, or straight when they have disclosed a bisexual identity.

• Don’t assume that bisexuality is just a phase or that youths are confused when they disclose their identity.

• Don’t assume you know a patient’s sexual orientation or behaviors on the basis of the sex of the current partner or current behaviors.

• Do ask open and nonjudgmental questions about sexual attraction and behaviors, and be familiar with the terms bisexual, queer, questioning, and pansexual in addition to lesbian, gay, and straight.

• Do use inclusive terms like LGBT when referring to the community rather than gay rights.

• Do recognize potential biases and assumptions regarding sexuality and bisexuality and work to change them.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Terms and definitions:

Bisexual – A person who can be attracted to more than one sex, gender, or gender identity. “Bi” is often used as an abbreviation.

Biphobia – Prejudice, fear, or hatred directed toward bisexual people.

Queer – A term people often use to express fluid identities and orientations. Historically considered a pejorative term, but used by many youth to describe their identity.

Pansexual – A person who can be attracted to any sex, gender, or gender identity.

References:
 

1. ”Health Disparities Among Bisexual People,” brief by the Human Rights Campaign Foundation.

2. “New Mexico’s Progress in Collecting Lesbian, Gay, Bisexual, and Transgender Health Data and Its Implications for Addressing Health Disparities,” New Mexico Department of Health, April 2010.

3. “Supporting and Caring for Our Bisexual Youth,” the Human Rights Campaign Foundation, 2014.

Lesbian, gay, bisexual, transgender, and questioning or queer (LGBTQ) youth face bias and discrimination within the health care setting and experience disparities in health, compared with their heterosexual cisgender peers. This is an area that is receiving increasing attention and study as health care providers and researchers work to achieve health equity within these populations.

Studies focusing specifically on the health of bisexual youth and adults are lacking. The few that do exist suggest that the experiences of people who identify as bisexual may be different from those who identify as lesbian or gay. Myths and misconceptions about bisexual, pansexual, queer, and fluid identities may in some cases put these populations at increased risks. Common myths include that bisexuality is just a phase or that youth who identify as bisexual are just confused. Studies suggest that bisexual youth account for almost half of youth who identify as LGBTQ. Understanding more about some of the challenges bisexual youth and adults may face can help us better care for all of our patients and families.

• Bisexual adults are more likely to engage in self-harming behaviors, attempt suicide, or think about suicide than heterosexual adults, lesbian women, or gay men.¹

• Bisexual women have higher rates of high blood pressure, compared with heterosexual and lesbian women.²

• Bisexual women have higher rates of alcohol-related disorders than lesbian and heterosexual women.¹

Some disparities appear to be related to lack of preventive care. A survey by the Williams Institute found that 39% of bisexual men and 33% of bisexual women did not disclose their sexual orientation, compared with 13% of gay men and 10% of lesbian women.¹ The effect of intersecting identities also must be considered when discussing these health disparities. More than 40% of LGBTQ people of color identify as bisexual, and almost half of transgender people describe their sexual orientation as bisexual or queer.¹ These individuals may be especially vulnerable to health disparities as they may experience a combination of racism, transphobia, and biphobia.

Risk factors for these disparities may develop early in life. A 2012 survey of LGBTQ youth found that:³

• Bisexual youth were less likely than lesbian and gay youth to report having supportive adults who they could turn to if they were sad.

• Only 5% of bisexual youth reported being very happy, compared with 8% of gay and lesbian youth and 21% of non-LGBT youth.

• Bisexual youth reported higher rates of experimentation with drugs and alcohol, compared with their lesbian, gay, and heterosexual peers.

• Bisexual youth reported lower levels of family acceptance and knowledge of social support systems in their communities than lesbian and gay youth. Both family acceptance and knowledge of social support systems have been identified as protective factors in the development of youth.

• Bisexual youth are less likely to be out to their friends, families, and communities.

As health care providers, recognizing, respecting, and supporting the identities of our bisexual patients is important. A few simple things we can do in practice are as follows:

• Don’t mislabel patients as lesbian, gay, or straight when they have disclosed a bisexual identity.

• Don’t assume that bisexuality is just a phase or that youths are confused when they disclose their identity.

• Don’t assume you know a patient’s sexual orientation or behaviors on the basis of the sex of the current partner or current behaviors.

• Do ask open and nonjudgmental questions about sexual attraction and behaviors, and be familiar with the terms bisexual, queer, questioning, and pansexual in addition to lesbian, gay, and straight.

• Do use inclusive terms like LGBT when referring to the community rather than gay rights.

• Do recognize potential biases and assumptions regarding sexuality and bisexuality and work to change them.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Terms and definitions:

Bisexual – A person who can be attracted to more than one sex, gender, or gender identity. “Bi” is often used as an abbreviation.

Biphobia – Prejudice, fear, or hatred directed toward bisexual people.

Queer – A term people often use to express fluid identities and orientations. Historically considered a pejorative term, but used by many youth to describe their identity.

Pansexual – A person who can be attracted to any sex, gender, or gender identity.

References:
 

1. ”Health Disparities Among Bisexual People,” brief by the Human Rights Campaign Foundation.

2. “New Mexico’s Progress in Collecting Lesbian, Gay, Bisexual, and Transgender Health Data and Its Implications for Addressing Health Disparities,” New Mexico Department of Health, April 2010.

3. “Supporting and Caring for Our Bisexual Youth,” the Human Rights Campaign Foundation, 2014.

The field of transgender health is growing. What began as a lone German physician in 1918 defying the norms of treating gender identity as a disease now has burgeoned into a field that includes 1,079 PubMed articles,two medical guidelines^1,2, and a multitude of books. As we learn more about the complexity of gender and gender identity, we also are discovering potential problems that occur when providing care to our transgender patients. One is eating disorders.

A systematic review by Jones et al. showed only a handful of studies on eating disorders in transgender individuals, most of them restricted to case studies.³ In some situations, the issue of gender identity arises during treatment for an eating disorder, as the individual realizes that body dissatisfaction is due to the gender identity instead of a fear of gaining weight. In other cases, a transgender person in the process of transitioning to the affirmed gender develops an eating disorder.

References

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

2. Adv Urol. 2012;2012:581712.

3. Int Rev Psychiatry. 2016;28(1):81-94.

4. J Adolesc Health. 2015 Aug;57(2):144-9.

5. J Adolesc Health. 2016. doi: 10.1016/j.jadohealth.2016.08.027.

6. Feeding and Eating Disorders. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).

7. Gender Dysphoria. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).

8. Psychol Bull. 2003 Sep;129(5):674-97.

9. Int J Law Psychiatry. 2003 Sep-Oct;26(5):533-48.

10. Arch Gen Psychiatry. 2011 Jul;68(7):724-31.

11. Clin Endocrinol (Oxf). 2010 Feb;72(2):214-31.

12. CNS drugs. 2006;20(8):655-63.

13. Int J Eat Disord. 2015 Nov;48(7):942-5.

14. Eat Disord. 2012;20(4):300-11.

The field of transgender health is growing. What began as a lone German physician in 1918 defying the norms of treating gender identity as a disease now has burgeoned into a field that includes 1,079 PubMed articles,two medical guidelines^1,2, and a multitude of books. As we learn more about the complexity of gender and gender identity, we also are discovering potential problems that occur when providing care to our transgender patients. One is eating disorders.

A systematic review by Jones et al. showed only a handful of studies on eating disorders in transgender individuals, most of them restricted to case studies.³ In some situations, the issue of gender identity arises during treatment for an eating disorder, as the individual realizes that body dissatisfaction is due to the gender identity instead of a fear of gaining weight. In other cases, a transgender person in the process of transitioning to the affirmed gender develops an eating disorder.

References

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

2. Adv Urol. 2012;2012:581712.

3. Int Rev Psychiatry. 2016;28(1):81-94.

4. J Adolesc Health. 2015 Aug;57(2):144-9.

5. J Adolesc Health. 2016. doi: 10.1016/j.jadohealth.2016.08.027.

6. Feeding and Eating Disorders. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).

7. Gender Dysphoria. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).

8. Psychol Bull. 2003 Sep;129(5):674-97.

9. Int J Law Psychiatry. 2003 Sep-Oct;26(5):533-48.

10. Arch Gen Psychiatry. 2011 Jul;68(7):724-31.

11. Clin Endocrinol (Oxf). 2010 Feb;72(2):214-31.

12. CNS drugs. 2006;20(8):655-63.

13. Int J Eat Disord. 2015 Nov;48(7):942-5.

14. Eat Disord. 2012;20(4):300-11.

The field of transgender health is growing. What began as a lone German physician in 1918 defying the norms of treating gender identity as a disease now has burgeoned into a field that includes 1,079 PubMed articles,two medical guidelines^1,2, and a multitude of books. As we learn more about the complexity of gender and gender identity, we also are discovering potential problems that occur when providing care to our transgender patients. One is eating disorders.

A systematic review by Jones et al. showed only a handful of studies on eating disorders in transgender individuals, most of them restricted to case studies.³ In some situations, the issue of gender identity arises during treatment for an eating disorder, as the individual realizes that body dissatisfaction is due to the gender identity instead of a fear of gaining weight. In other cases, a transgender person in the process of transitioning to the affirmed gender develops an eating disorder.

References

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

2. Adv Urol. 2012;2012:581712.

3. Int Rev Psychiatry. 2016;28(1):81-94.

4. J Adolesc Health. 2015 Aug;57(2):144-9.

5. J Adolesc Health. 2016. doi: 10.1016/j.jadohealth.2016.08.027.

6. Feeding and Eating Disorders. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).

7. Gender Dysphoria. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).

8. Psychol Bull. 2003 Sep;129(5):674-97.

9. Int J Law Psychiatry. 2003 Sep-Oct;26(5):533-48.

10. Arch Gen Psychiatry. 2011 Jul;68(7):724-31.

11. Clin Endocrinol (Oxf). 2010 Feb;72(2):214-31.

12. CNS drugs. 2006;20(8):655-63.

13. Int J Eat Disord. 2015 Nov;48(7):942-5.

14. Eat Disord. 2012;20(4):300-11.

For many the beginning of a new year is a time to set goals and resolutions for the upcoming year. Often these resolutions are related to health, for example, quit smoking, work out more, lose weight. It is sometimes easy to overlook mental health and well-being as an integral part of overall wellness. This month’s column will focus on how as pediatric providers we can help promote the mental well-being of our patients in practice.

Mental health problems are a significant cause of morbidity and mortality in youth. In 2014, suicide was the second leading cause of death for all youth 10-14 years and 15-24 years.¹ While most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) persons live healthy, happy lives, LGBTQ youth are at disproportionate risk for mental illness, probably related to lack of support and to stigma related to their sexual minority and gender minority identities. Studies suggest that LGBTQ youth have suicidality rates two to five times higher than their heterosexual cisgender peers.^2,3,4

• Principle 1. A comprehensive diagnostic evaluation should include an age-appropriate assessment of psychosexual development for all youths.

While pediatric providers are unlikely to perform a comprehensive mental health diagnostic evaluation, psychosocial development should regularly be assessed at well visits. It may not be readily apparent which youth are struggling with development of their sexual and gender identity. Nonassuming questions regarding development in theses domains should ideally be integrated into the psychosocial assessment. For example, begin a sexual history by asking, “Are you romantically attracted to males, females, both, or neither?”

• Principle 2. The need for confidentiality in the clinical alliance is a special consideration in the assessment of sexual and gender minority youth.

Confidentiality is important when talking to any youth about their sexual and gender identity. LGBTQ youth in particular may have concerns of family or provider rejection, and they may look for cues that they can safely discuss their sexuality or gender identity without fear of being judged or shamed. Clinicians should be aware of confidentiality practices for minors when discussing these issues. Potential risks of premature disclosure to family and support systems, such as rejection or alienation, also should be considered.

• Principle 3. Family dynamics pertinent to sexual orientation, gender nonconformity, and gender identity should be explored in the context of the cultural values of the youth, family, and community.

Families can have a variety of responses to their child’s sexual minority or gender minority identity, ranging from acceptance to rejection, with some youth being forced to leave home. Many families need to alter their ideas and expectations for a child after their child comes out, and this can lead to feelings of loss and grief accompanied by feelings of anxiety, anger, shame, and guilt.⁵ Over time, however, the majority of families become affirming and supportive and are not distressed.⁷ Recognizing that family support reduces negative health outcomes for youth, providers should aim to support and preserve positive family relationships when possible. This may involve education and support for families as well as youth. It is important to be aware that sexual and gender minority youth who are also members of ethnic minorities may face additional challenges.

• Principle 4. Clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased psychiatric risk.

Providers should recognize that LGBTQ youth are at disproportionate risk of bullying, suicide, substance use, high-risk sexual behaviors, running away, and becoming homeless. Providers should assess for these risks and address them as appropriate.

• Principle 5. Clinicians should aim to foster healthy psychosexual development in sexual and gender minority youth, and protect these individuals’ full capacity for integrated identity formation and functioning.

Providers should support healthy youth development and self-discovery, recognizing that there is a spectrum of sexual and gender identities, with the goal of helping youth achieve their full developmental potential.

• Principle 6. Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and attempts to do so may be harmful.

Therapies targeted at altering sexual orientation or gender identity, often referred to as reparative therapies, can encourage family rejection and decrease self-esteem and connectedness, all of which have been identified as risk factors for suicidality. Providers should educate parents about the potential harm of these types of therapies and ensure that mental health providers to whom patients are being referred are not practicing these potentially harmful therapies.

• Principle 7. Clinicians should be aware of current evidence on the natural course of gender discordance and associated psychopathology in children and adolescents in choosing the treatment goals and modality.

Variation in gender role behavior (for example, dress preference, toy preference, types of play) is typical in early childhood and should be distinguished from gender dysphoria, in which a child expresses distress related to a gender identity that is different from or does not fully align with the child’s sex assigned at birth. Assessing gender development in childhood and the best approach to treatment is best done by professionals with experience and training in gender development, and providers should be familiar with resources in their area. For some, gender identity concerns may not be recognized until adolescence when the onset of puberty and secondary sex characteristics result in increased dysphoria. Best practice guidelines exist for treatment of youth with gender discordance, and there is limited but growing evidence to support best practices. Providers should ensure that the providers and specialists to whom families are referred practice according to current best practices.

• Principle 8. Clinicians should be prepared to consult and act as a liaison with schools, community agencies, and other health care providers, advocating for the unique needs of sexual and gender minority youth and their families.

Pediatric providers can work with mental health professionals to be advocates for their gender and sexual minority patients and raise awareness of issues affecting these special populations such as bullying and suicidality.

• Principle 9. Mental health professionals should be aware of community and professional resources relevant to sexual and gender minority youth.

As medical providers, we have a limited amount of time to see and assess patients, and often are able to best serve our patients and families by connecting them to specialists in the medical community and resources available in the school and community. It is important to know what resources exist in the community to be able to appropriately refer and connect patients.

Resources for providers

• American Academy of Child and Adolescent Psychiatry Practice Parameter on lesbian, gay, bisexual, and transgender youth .

• National LGBT Health Education Center: Training materials and modules with continuing education credits.

Resources for families

• Gay, Lesbian, and Straight Education Network.• Parents, Friends, Families of Lesbians and Gays (PFLAG).

References

1. “10 Leading Causes of Death by Age Group, United States – 2014,” National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

2. Lesbian, Gay, Bisexual, and Transgender Health: LGBT Youth, Centers for Disease Control and Prevention, Nov. 12, 2014.

3. Am J Public Health. 2001 Aug;91(8):1276-81.

4. Am J Prev Med. 2012 Mar;42(3):221-8.

5. J. Am Acad Child Adolesc Psychiatry. 2012;51(9):957–74.

6. Pediatr Clin North Am. 2016 Dec;63(6):971-83.

7. “Mom, Dad. I’m Gay: How Families Negotiate Coming Out” (Washington, DC: American Psychological Association, 2001).

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.

For many the beginning of a new year is a time to set goals and resolutions for the upcoming year. Often these resolutions are related to health, for example, quit smoking, work out more, lose weight. It is sometimes easy to overlook mental health and well-being as an integral part of overall wellness. This month’s column will focus on how as pediatric providers we can help promote the mental well-being of our patients in practice.

Mental health problems are a significant cause of morbidity and mortality in youth. In 2014, suicide was the second leading cause of death for all youth 10-14 years and 15-24 years.¹ While most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) persons live healthy, happy lives, LGBTQ youth are at disproportionate risk for mental illness, probably related to lack of support and to stigma related to their sexual minority and gender minority identities. Studies suggest that LGBTQ youth have suicidality rates two to five times higher than their heterosexual cisgender peers.^2,3,4

• Principle 1. A comprehensive diagnostic evaluation should include an age-appropriate assessment of psychosexual development for all youths.

While pediatric providers are unlikely to perform a comprehensive mental health diagnostic evaluation, psychosocial development should regularly be assessed at well visits. It may not be readily apparent which youth are struggling with development of their sexual and gender identity. Nonassuming questions regarding development in theses domains should ideally be integrated into the psychosocial assessment. For example, begin a sexual history by asking, “Are you romantically attracted to males, females, both, or neither?”

• Principle 2. The need for confidentiality in the clinical alliance is a special consideration in the assessment of sexual and gender minority youth.

Confidentiality is important when talking to any youth about their sexual and gender identity. LGBTQ youth in particular may have concerns of family or provider rejection, and they may look for cues that they can safely discuss their sexuality or gender identity without fear of being judged or shamed. Clinicians should be aware of confidentiality practices for minors when discussing these issues. Potential risks of premature disclosure to family and support systems, such as rejection or alienation, also should be considered.

• Principle 3. Family dynamics pertinent to sexual orientation, gender nonconformity, and gender identity should be explored in the context of the cultural values of the youth, family, and community.

Families can have a variety of responses to their child’s sexual minority or gender minority identity, ranging from acceptance to rejection, with some youth being forced to leave home. Many families need to alter their ideas and expectations for a child after their child comes out, and this can lead to feelings of loss and grief accompanied by feelings of anxiety, anger, shame, and guilt.⁵ Over time, however, the majority of families become affirming and supportive and are not distressed.⁷ Recognizing that family support reduces negative health outcomes for youth, providers should aim to support and preserve positive family relationships when possible. This may involve education and support for families as well as youth. It is important to be aware that sexual and gender minority youth who are also members of ethnic minorities may face additional challenges.

• Principle 4. Clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased psychiatric risk.

Providers should recognize that LGBTQ youth are at disproportionate risk of bullying, suicide, substance use, high-risk sexual behaviors, running away, and becoming homeless. Providers should assess for these risks and address them as appropriate.

• Principle 5. Clinicians should aim to foster healthy psychosexual development in sexual and gender minority youth, and protect these individuals’ full capacity for integrated identity formation and functioning.

Providers should support healthy youth development and self-discovery, recognizing that there is a spectrum of sexual and gender identities, with the goal of helping youth achieve their full developmental potential.

• Principle 6. Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and attempts to do so may be harmful.

Therapies targeted at altering sexual orientation or gender identity, often referred to as reparative therapies, can encourage family rejection and decrease self-esteem and connectedness, all of which have been identified as risk factors for suicidality. Providers should educate parents about the potential harm of these types of therapies and ensure that mental health providers to whom patients are being referred are not practicing these potentially harmful therapies.

• Principle 7. Clinicians should be aware of current evidence on the natural course of gender discordance and associated psychopathology in children and adolescents in choosing the treatment goals and modality.

Variation in gender role behavior (for example, dress preference, toy preference, types of play) is typical in early childhood and should be distinguished from gender dysphoria, in which a child expresses distress related to a gender identity that is different from or does not fully align with the child’s sex assigned at birth. Assessing gender development in childhood and the best approach to treatment is best done by professionals with experience and training in gender development, and providers should be familiar with resources in their area. For some, gender identity concerns may not be recognized until adolescence when the onset of puberty and secondary sex characteristics result in increased dysphoria. Best practice guidelines exist for treatment of youth with gender discordance, and there is limited but growing evidence to support best practices. Providers should ensure that the providers and specialists to whom families are referred practice according to current best practices.

• Principle 8. Clinicians should be prepared to consult and act as a liaison with schools, community agencies, and other health care providers, advocating for the unique needs of sexual and gender minority youth and their families.

Pediatric providers can work with mental health professionals to be advocates for their gender and sexual minority patients and raise awareness of issues affecting these special populations such as bullying and suicidality.

• Principle 9. Mental health professionals should be aware of community and professional resources relevant to sexual and gender minority youth.

As medical providers, we have a limited amount of time to see and assess patients, and often are able to best serve our patients and families by connecting them to specialists in the medical community and resources available in the school and community. It is important to know what resources exist in the community to be able to appropriately refer and connect patients.

Resources for providers

• American Academy of Child and Adolescent Psychiatry Practice Parameter on lesbian, gay, bisexual, and transgender youth .

• National LGBT Health Education Center: Training materials and modules with continuing education credits.

Resources for families

• Gay, Lesbian, and Straight Education Network.• Parents, Friends, Families of Lesbians and Gays (PFLAG).

References

1. “10 Leading Causes of Death by Age Group, United States – 2014,” National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

2. Lesbian, Gay, Bisexual, and Transgender Health: LGBT Youth, Centers for Disease Control and Prevention, Nov. 12, 2014.

3. Am J Public Health. 2001 Aug;91(8):1276-81.

4. Am J Prev Med. 2012 Mar;42(3):221-8.

5. J. Am Acad Child Adolesc Psychiatry. 2012;51(9):957–74.

6. Pediatr Clin North Am. 2016 Dec;63(6):971-83.

7. “Mom, Dad. I’m Gay: How Families Negotiate Coming Out” (Washington, DC: American Psychological Association, 2001).

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.

For many the beginning of a new year is a time to set goals and resolutions for the upcoming year. Often these resolutions are related to health, for example, quit smoking, work out more, lose weight. It is sometimes easy to overlook mental health and well-being as an integral part of overall wellness. This month’s column will focus on how as pediatric providers we can help promote the mental well-being of our patients in practice.

Mental health problems are a significant cause of morbidity and mortality in youth. In 2014, suicide was the second leading cause of death for all youth 10-14 years and 15-24 years.¹ While most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) persons live healthy, happy lives, LGBTQ youth are at disproportionate risk for mental illness, probably related to lack of support and to stigma related to their sexual minority and gender minority identities. Studies suggest that LGBTQ youth have suicidality rates two to five times higher than their heterosexual cisgender peers.^2,3,4

• Principle 1. A comprehensive diagnostic evaluation should include an age-appropriate assessment of psychosexual development for all youths.

While pediatric providers are unlikely to perform a comprehensive mental health diagnostic evaluation, psychosocial development should regularly be assessed at well visits. It may not be readily apparent which youth are struggling with development of their sexual and gender identity. Nonassuming questions regarding development in theses domains should ideally be integrated into the psychosocial assessment. For example, begin a sexual history by asking, “Are you romantically attracted to males, females, both, or neither?”

• Principle 2. The need for confidentiality in the clinical alliance is a special consideration in the assessment of sexual and gender minority youth.

Confidentiality is important when talking to any youth about their sexual and gender identity. LGBTQ youth in particular may have concerns of family or provider rejection, and they may look for cues that they can safely discuss their sexuality or gender identity without fear of being judged or shamed. Clinicians should be aware of confidentiality practices for minors when discussing these issues. Potential risks of premature disclosure to family and support systems, such as rejection or alienation, also should be considered.

• Principle 3. Family dynamics pertinent to sexual orientation, gender nonconformity, and gender identity should be explored in the context of the cultural values of the youth, family, and community.

Families can have a variety of responses to their child’s sexual minority or gender minority identity, ranging from acceptance to rejection, with some youth being forced to leave home. Many families need to alter their ideas and expectations for a child after their child comes out, and this can lead to feelings of loss and grief accompanied by feelings of anxiety, anger, shame, and guilt.⁵ Over time, however, the majority of families become affirming and supportive and are not distressed.⁷ Recognizing that family support reduces negative health outcomes for youth, providers should aim to support and preserve positive family relationships when possible. This may involve education and support for families as well as youth. It is important to be aware that sexual and gender minority youth who are also members of ethnic minorities may face additional challenges.

• Principle 4. Clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased psychiatric risk.

Providers should recognize that LGBTQ youth are at disproportionate risk of bullying, suicide, substance use, high-risk sexual behaviors, running away, and becoming homeless. Providers should assess for these risks and address them as appropriate.

• Principle 5. Clinicians should aim to foster healthy psychosexual development in sexual and gender minority youth, and protect these individuals’ full capacity for integrated identity formation and functioning.

Providers should support healthy youth development and self-discovery, recognizing that there is a spectrum of sexual and gender identities, with the goal of helping youth achieve their full developmental potential.

• Principle 6. Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and attempts to do so may be harmful.

Therapies targeted at altering sexual orientation or gender identity, often referred to as reparative therapies, can encourage family rejection and decrease self-esteem and connectedness, all of which have been identified as risk factors for suicidality. Providers should educate parents about the potential harm of these types of therapies and ensure that mental health providers to whom patients are being referred are not practicing these potentially harmful therapies.

• Principle 7. Clinicians should be aware of current evidence on the natural course of gender discordance and associated psychopathology in children and adolescents in choosing the treatment goals and modality.

Variation in gender role behavior (for example, dress preference, toy preference, types of play) is typical in early childhood and should be distinguished from gender dysphoria, in which a child expresses distress related to a gender identity that is different from or does not fully align with the child’s sex assigned at birth. Assessing gender development in childhood and the best approach to treatment is best done by professionals with experience and training in gender development, and providers should be familiar with resources in their area. For some, gender identity concerns may not be recognized until adolescence when the onset of puberty and secondary sex characteristics result in increased dysphoria. Best practice guidelines exist for treatment of youth with gender discordance, and there is limited but growing evidence to support best practices. Providers should ensure that the providers and specialists to whom families are referred practice according to current best practices.

• Principle 8. Clinicians should be prepared to consult and act as a liaison with schools, community agencies, and other health care providers, advocating for the unique needs of sexual and gender minority youth and their families.

Pediatric providers can work with mental health professionals to be advocates for their gender and sexual minority patients and raise awareness of issues affecting these special populations such as bullying and suicidality.

• Principle 9. Mental health professionals should be aware of community and professional resources relevant to sexual and gender minority youth.

As medical providers, we have a limited amount of time to see and assess patients, and often are able to best serve our patients and families by connecting them to specialists in the medical community and resources available in the school and community. It is important to know what resources exist in the community to be able to appropriately refer and connect patients.

Resources for providers

• American Academy of Child and Adolescent Psychiatry Practice Parameter on lesbian, gay, bisexual, and transgender youth .

• National LGBT Health Education Center: Training materials and modules with continuing education credits.

Resources for families

• Gay, Lesbian, and Straight Education Network.• Parents, Friends, Families of Lesbians and Gays (PFLAG).

References

1. “10 Leading Causes of Death by Age Group, United States – 2014,” National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

2. Lesbian, Gay, Bisexual, and Transgender Health: LGBT Youth, Centers for Disease Control and Prevention, Nov. 12, 2014.

3. Am J Public Health. 2001 Aug;91(8):1276-81.

4. Am J Prev Med. 2012 Mar;42(3):221-8.

5. J. Am Acad Child Adolesc Psychiatry. 2012;51(9):957–74.

6. Pediatr Clin North Am. 2016 Dec;63(6):971-83.

7. “Mom, Dad. I’m Gay: How Families Negotiate Coming Out” (Washington, DC: American Psychological Association, 2001).

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.