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Addressing sexuality, gender identity issues is key to positive outcomes
A while ago, I gave a talk on LGBT health to a group of primary care pediatricians. Although I was glad that they invited me to speak, I also sensed some discomfort in the audience. At the end of the lecture, many pediatricians told me that they were uncomfortable with bringing up the topic of sexuality and gender identity with their patients, and others wanted guidance on how to ask questions on sexuality and gender identity.
There are many barriers for primary pediatricians in addressing sexuality and gender identity concerns in their patients. First, pediatricians often will have up to 15 minutes for a visit, so they will have little time to address a complex issue. Second, primary care pediatricians may have known many of their patients since birth, and asking questions on sexuality and gender can feel awkward. Finally, many pediatricians may be working in more conservative areas in the country where asking questions on sexuality and gender identity may be controversial.
Although a very important topic, there is not much empirical evidence on how to ask questions on sexuality and gender appropriately, and most of these recommendations are based on my own experience working with LGBT youth. Regardless, I hope these pointers will help the primary care pediatrician address the needs of LGBT youth efficiently and with sensitivity.
Tip No. 1: The environment counts
I cannot overstate how important it is to make your clinic a welcoming place for LGBT youth. Having various signs and stickers – like rainbow flags or the Human Rights Campaign sticker – will signal to LGBT youth that they are safe in your clinic. Creating a safe and welcoming environment is important because many people in the LGBT community have experienced rejection and discrimination from their primary care doctors.1 Making your clinic a safe space will make it easier and efficient for patients to ask questions about sexuality and gender identity (see Dr. Gaya Chelvakumar’s column “Creating safe spaces for LGBTQ youth, families in health care settings” at pediatricnews.com).
Tip No. 2: Consider the context
Most likely, many presenting complaints – such as colds or sports injuries – of your adolescent patients will not involve sexual orientation or gender identity. There are exceptions. If you suspect an STD, then the risk for certain infections, such as HIV2 or gonorrhea of the anus or of the pharynx3 are higher in gay young men. For the latter, your screening method would be different (that is, obtaining a pharyngeal swab or an anal swab instead of a urine sample). Also, because many LGBT youth have higher rates of mental health problems compared with heterosexual youth,4 you may want to ask questions about sexuality or gender identity to patients complaining of depressive or anxiety symptoms. This is especially important for transgender youth, because the implementation of pubertal blockers or cross-sex hormones can be therapeutic.5 To prevent or reduce many of these health problems, asking about sexuality and gender identity is a good idea during the well visit, when you may have more time.
Tip No. 3: Not all developmental stages are considered equal
Adolescence is a period of rapid and phasic growth. Formation of an identity is one of the major psychosocial tasks for adolescence,6 and sexuality and gender are important identities. In general, in early adolescence identity becomes an issue as the teenager gains autonomy from parents. I typically start asking questions about sexuality and gender when the patient is 11 or 12, because many children may not understand sexuality and gender identity at a younger age. At these ages, I ask these questions with the parents in the room, then I ask them confidentially on subsequent well visits. This approach serves two purposes: it will prepare the adolescent for these complex and thought-provoking questions in future encounters, and it gives the parents an idea of the type of questions you will ask the children when they are old enough for the confidential visit, helping parents feel more comfortable in stepping out of the room during this time.
Tip No. 4: Keep it confidential
Many adolescents are reluctant to see a doctor, even if they are sick. The primary reason adolescents do not seek care is the fear that the provider will tell their parents about their illness.7 Although this should be applicable to all of your adolescent patients, you should make an extra effort to explicitly state to LGBT patients that the clinic visit is confidential (with the exception of risk of suicide, homicide, or child abuse). This is important for LGBT youth who are not out to their parents and may be in danger if they do come out.8
Tip No. 5: Normalize, normalize, normalize
Because of the stigma and discrimination surrounding sexual orientation and gender identity, many LGBT youth will be reluctant to disclose their sexual orientation or gender identity to their health care providers. At the same time, heterosexual youth may think that you’re asking them questions about sexuality or gender identity because you suspect them to be a member of the LGBT community. To avoid this awkward situation, many pediatricians do not ask these questions at all. A good remedy for this is to preface your questions about sexual orientation or gender identity by saying that you ask these questions to all your patients – that way no one feels singled out.
Tip No. 6: Ask for permission
As previously mentioned, members of the LGBT community may experience discrimination from their health care providers after disclosing to them their sexual orientation or gender identity.1 This rejection can be traumatizing for LGBT youth, making them reluctant to discuss any issues related to sexual orientation or gender identity with any medical provider. As part of the trauma-informed approach, asking for permission before delving into issues related to sexual orientation and gender identity will give LGBT patients a sense of control, especially in an environment where there is a significant power differential.
Tip No. 7: Treat this as a skill
Despite the pressures for primary care pediatricians to maintain an efficient and effective clinical practice, many strive to learn new skills to provide the best care for their patients. Asking questions about sexuality and gender identity should be one of those skills. As with any skill, it will feel unnatural at first, and it will require practice. Mastering this skill, however, will help you address the health needs of this vulnerable population.
Asking questions about sexuality and gender identity is difficult for the primary care pediatrician. Hopefully, these tips can help you develop this important skill. It will also help you reach out to a population that is wary of the health care system.
References
1. J Am Board Fam Med. 2016;29(1):156-60.
2. https://www.cdc.gov/hiv/group/msm/index.html.
3. https://www.cdc.gov/std/tg2015/default.htm.
4. J Adolesc Health. 2011;49(2):115-23.
5. Nat Rev Endocrinol. 2011;7(8):466-72.
6. Neinstein LS. Adolescent health care: a practical guide. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.
7. J Adolesc Health. 2007;40(3):218-26.
8. Am J Orthopsychiatry. 1998;68(3):361-71.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.
A while ago, I gave a talk on LGBT health to a group of primary care pediatricians. Although I was glad that they invited me to speak, I also sensed some discomfort in the audience. At the end of the lecture, many pediatricians told me that they were uncomfortable with bringing up the topic of sexuality and gender identity with their patients, and others wanted guidance on how to ask questions on sexuality and gender identity.
There are many barriers for primary pediatricians in addressing sexuality and gender identity concerns in their patients. First, pediatricians often will have up to 15 minutes for a visit, so they will have little time to address a complex issue. Second, primary care pediatricians may have known many of their patients since birth, and asking questions on sexuality and gender can feel awkward. Finally, many pediatricians may be working in more conservative areas in the country where asking questions on sexuality and gender identity may be controversial.
Although a very important topic, there is not much empirical evidence on how to ask questions on sexuality and gender appropriately, and most of these recommendations are based on my own experience working with LGBT youth. Regardless, I hope these pointers will help the primary care pediatrician address the needs of LGBT youth efficiently and with sensitivity.
Tip No. 1: The environment counts
I cannot overstate how important it is to make your clinic a welcoming place for LGBT youth. Having various signs and stickers – like rainbow flags or the Human Rights Campaign sticker – will signal to LGBT youth that they are safe in your clinic. Creating a safe and welcoming environment is important because many people in the LGBT community have experienced rejection and discrimination from their primary care doctors.1 Making your clinic a safe space will make it easier and efficient for patients to ask questions about sexuality and gender identity (see Dr. Gaya Chelvakumar’s column “Creating safe spaces for LGBTQ youth, families in health care settings” at pediatricnews.com).
Tip No. 2: Consider the context
Most likely, many presenting complaints – such as colds or sports injuries – of your adolescent patients will not involve sexual orientation or gender identity. There are exceptions. If you suspect an STD, then the risk for certain infections, such as HIV2 or gonorrhea of the anus or of the pharynx3 are higher in gay young men. For the latter, your screening method would be different (that is, obtaining a pharyngeal swab or an anal swab instead of a urine sample). Also, because many LGBT youth have higher rates of mental health problems compared with heterosexual youth,4 you may want to ask questions about sexuality or gender identity to patients complaining of depressive or anxiety symptoms. This is especially important for transgender youth, because the implementation of pubertal blockers or cross-sex hormones can be therapeutic.5 To prevent or reduce many of these health problems, asking about sexuality and gender identity is a good idea during the well visit, when you may have more time.
Tip No. 3: Not all developmental stages are considered equal
Adolescence is a period of rapid and phasic growth. Formation of an identity is one of the major psychosocial tasks for adolescence,6 and sexuality and gender are important identities. In general, in early adolescence identity becomes an issue as the teenager gains autonomy from parents. I typically start asking questions about sexuality and gender when the patient is 11 or 12, because many children may not understand sexuality and gender identity at a younger age. At these ages, I ask these questions with the parents in the room, then I ask them confidentially on subsequent well visits. This approach serves two purposes: it will prepare the adolescent for these complex and thought-provoking questions in future encounters, and it gives the parents an idea of the type of questions you will ask the children when they are old enough for the confidential visit, helping parents feel more comfortable in stepping out of the room during this time.
Tip No. 4: Keep it confidential
Many adolescents are reluctant to see a doctor, even if they are sick. The primary reason adolescents do not seek care is the fear that the provider will tell their parents about their illness.7 Although this should be applicable to all of your adolescent patients, you should make an extra effort to explicitly state to LGBT patients that the clinic visit is confidential (with the exception of risk of suicide, homicide, or child abuse). This is important for LGBT youth who are not out to their parents and may be in danger if they do come out.8
Tip No. 5: Normalize, normalize, normalize
Because of the stigma and discrimination surrounding sexual orientation and gender identity, many LGBT youth will be reluctant to disclose their sexual orientation or gender identity to their health care providers. At the same time, heterosexual youth may think that you’re asking them questions about sexuality or gender identity because you suspect them to be a member of the LGBT community. To avoid this awkward situation, many pediatricians do not ask these questions at all. A good remedy for this is to preface your questions about sexual orientation or gender identity by saying that you ask these questions to all your patients – that way no one feels singled out.
Tip No. 6: Ask for permission
As previously mentioned, members of the LGBT community may experience discrimination from their health care providers after disclosing to them their sexual orientation or gender identity.1 This rejection can be traumatizing for LGBT youth, making them reluctant to discuss any issues related to sexual orientation or gender identity with any medical provider. As part of the trauma-informed approach, asking for permission before delving into issues related to sexual orientation and gender identity will give LGBT patients a sense of control, especially in an environment where there is a significant power differential.
Tip No. 7: Treat this as a skill
Despite the pressures for primary care pediatricians to maintain an efficient and effective clinical practice, many strive to learn new skills to provide the best care for their patients. Asking questions about sexuality and gender identity should be one of those skills. As with any skill, it will feel unnatural at first, and it will require practice. Mastering this skill, however, will help you address the health needs of this vulnerable population.
Asking questions about sexuality and gender identity is difficult for the primary care pediatrician. Hopefully, these tips can help you develop this important skill. It will also help you reach out to a population that is wary of the health care system.
References
1. J Am Board Fam Med. 2016;29(1):156-60.
2. https://www.cdc.gov/hiv/group/msm/index.html.
3. https://www.cdc.gov/std/tg2015/default.htm.
4. J Adolesc Health. 2011;49(2):115-23.
5. Nat Rev Endocrinol. 2011;7(8):466-72.
6. Neinstein LS. Adolescent health care: a practical guide. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.
7. J Adolesc Health. 2007;40(3):218-26.
8. Am J Orthopsychiatry. 1998;68(3):361-71.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.
A while ago, I gave a talk on LGBT health to a group of primary care pediatricians. Although I was glad that they invited me to speak, I also sensed some discomfort in the audience. At the end of the lecture, many pediatricians told me that they were uncomfortable with bringing up the topic of sexuality and gender identity with their patients, and others wanted guidance on how to ask questions on sexuality and gender identity.
There are many barriers for primary pediatricians in addressing sexuality and gender identity concerns in their patients. First, pediatricians often will have up to 15 minutes for a visit, so they will have little time to address a complex issue. Second, primary care pediatricians may have known many of their patients since birth, and asking questions on sexuality and gender can feel awkward. Finally, many pediatricians may be working in more conservative areas in the country where asking questions on sexuality and gender identity may be controversial.
Although a very important topic, there is not much empirical evidence on how to ask questions on sexuality and gender appropriately, and most of these recommendations are based on my own experience working with LGBT youth. Regardless, I hope these pointers will help the primary care pediatrician address the needs of LGBT youth efficiently and with sensitivity.
Tip No. 1: The environment counts
I cannot overstate how important it is to make your clinic a welcoming place for LGBT youth. Having various signs and stickers – like rainbow flags or the Human Rights Campaign sticker – will signal to LGBT youth that they are safe in your clinic. Creating a safe and welcoming environment is important because many people in the LGBT community have experienced rejection and discrimination from their primary care doctors.1 Making your clinic a safe space will make it easier and efficient for patients to ask questions about sexuality and gender identity (see Dr. Gaya Chelvakumar’s column “Creating safe spaces for LGBTQ youth, families in health care settings” at pediatricnews.com).
Tip No. 2: Consider the context
Most likely, many presenting complaints – such as colds or sports injuries – of your adolescent patients will not involve sexual orientation or gender identity. There are exceptions. If you suspect an STD, then the risk for certain infections, such as HIV2 or gonorrhea of the anus or of the pharynx3 are higher in gay young men. For the latter, your screening method would be different (that is, obtaining a pharyngeal swab or an anal swab instead of a urine sample). Also, because many LGBT youth have higher rates of mental health problems compared with heterosexual youth,4 you may want to ask questions about sexuality or gender identity to patients complaining of depressive or anxiety symptoms. This is especially important for transgender youth, because the implementation of pubertal blockers or cross-sex hormones can be therapeutic.5 To prevent or reduce many of these health problems, asking about sexuality and gender identity is a good idea during the well visit, when you may have more time.
Tip No. 3: Not all developmental stages are considered equal
Adolescence is a period of rapid and phasic growth. Formation of an identity is one of the major psychosocial tasks for adolescence,6 and sexuality and gender are important identities. In general, in early adolescence identity becomes an issue as the teenager gains autonomy from parents. I typically start asking questions about sexuality and gender when the patient is 11 or 12, because many children may not understand sexuality and gender identity at a younger age. At these ages, I ask these questions with the parents in the room, then I ask them confidentially on subsequent well visits. This approach serves two purposes: it will prepare the adolescent for these complex and thought-provoking questions in future encounters, and it gives the parents an idea of the type of questions you will ask the children when they are old enough for the confidential visit, helping parents feel more comfortable in stepping out of the room during this time.
Tip No. 4: Keep it confidential
Many adolescents are reluctant to see a doctor, even if they are sick. The primary reason adolescents do not seek care is the fear that the provider will tell their parents about their illness.7 Although this should be applicable to all of your adolescent patients, you should make an extra effort to explicitly state to LGBT patients that the clinic visit is confidential (with the exception of risk of suicide, homicide, or child abuse). This is important for LGBT youth who are not out to their parents and may be in danger if they do come out.8
Tip No. 5: Normalize, normalize, normalize
Because of the stigma and discrimination surrounding sexual orientation and gender identity, many LGBT youth will be reluctant to disclose their sexual orientation or gender identity to their health care providers. At the same time, heterosexual youth may think that you’re asking them questions about sexuality or gender identity because you suspect them to be a member of the LGBT community. To avoid this awkward situation, many pediatricians do not ask these questions at all. A good remedy for this is to preface your questions about sexual orientation or gender identity by saying that you ask these questions to all your patients – that way no one feels singled out.
Tip No. 6: Ask for permission
As previously mentioned, members of the LGBT community may experience discrimination from their health care providers after disclosing to them their sexual orientation or gender identity.1 This rejection can be traumatizing for LGBT youth, making them reluctant to discuss any issues related to sexual orientation or gender identity with any medical provider. As part of the trauma-informed approach, asking for permission before delving into issues related to sexual orientation and gender identity will give LGBT patients a sense of control, especially in an environment where there is a significant power differential.
Tip No. 7: Treat this as a skill
Despite the pressures for primary care pediatricians to maintain an efficient and effective clinical practice, many strive to learn new skills to provide the best care for their patients. Asking questions about sexuality and gender identity should be one of those skills. As with any skill, it will feel unnatural at first, and it will require practice. Mastering this skill, however, will help you address the health needs of this vulnerable population.
Asking questions about sexuality and gender identity is difficult for the primary care pediatrician. Hopefully, these tips can help you develop this important skill. It will also help you reach out to a population that is wary of the health care system.
References
1. J Am Board Fam Med. 2016;29(1):156-60.
2. https://www.cdc.gov/hiv/group/msm/index.html.
3. https://www.cdc.gov/std/tg2015/default.htm.
4. J Adolesc Health. 2011;49(2):115-23.
5. Nat Rev Endocrinol. 2011;7(8):466-72.
6. Neinstein LS. Adolescent health care: a practical guide. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.
7. J Adolesc Health. 2007;40(3):218-26.
8. Am J Orthopsychiatry. 1998;68(3):361-71.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.
Fear and hope: Helping LGBT youth cope with the 2016 election results
The day after the election, Time magazine reported an increased call volume to the Trevor Project, an organization that provides suicide counseling for LGBT youth.1 A colleague of mine who works closely with the Trevor Project told me that this was the second-highest call volume the organization has received since its inception.
Regardless of your political affiliation, we all can agree that this year’s election was divisive. Many minority groups, including the LGBT community, felt singled out. Although many of us have seen contentious elections in our lifetimes, teenagers, especially LGBT youth, are sensitive to this divisiveness.
Many LGBT youth who called the Trevor Project had expressed fear about the future. Whenever someone becomes suicidal, they have an overwhelming sense of hopelessness.2 Many perceive that the upcoming administration may be hostile to the LGBT community, and because many fear that this new administration may undo all the progress made in LGBT rights in the last 8 years, they have little hope for the future. Numerous reports of increased hate-crime incidents since the start of the election season last year may have exacerbated this feeling of hopelessness.3 This hopelessness may cause many to feel that the best way out is through suicide. Others feel that their sexual orientation or gender identity may be an additional burden to their family during this new era, and so to relieve them of this burden, they consider ending their own lives.4
For adults who have seen many administrations come and go, this may seem like hyperbole. But we have the advantage of living through various elections and administrations, knowing that they were not as catastrophic as others claimed. However, for many LGBT teens or young adults, this is probably their first election after reaching adolescence since Obama was elected in 2008. The Obama administration has been friendly to the LGBT community,5 and for LGBT youth, the upcoming Trump administration may be a substantial departure from this friendliness. In addition, people across the political spectrum have stoked fears among LGBT youth that the new administration will be devastating for the LGBT community. Adolescents, compared with adults, respond more strongly to the limbic system of the brain – the part of the brain involved in emotional processing, which includes fear.6 This fear will override any attempt by the prefrontal cortex – the part of the brain involved in cognitive processing6 – to put the results of this election within context and within perspective. In other words, it is easier for the adolescent brain to become much more despondent over a disappointing outcome.
What can providers do for LGBT youth who feel distressed over the outcome of the election? The approach is twofold. First, address the emotions emanating from the limbic system. Once this influence is dampened, engage the prefrontal cortex to process the emotions and address these fears in a more constructive way.
For LGBT youth who are actively suicidal, providers should first determine the risk for suicide (for example, determine the level of family support, access to lethal means of suicide, etc.) Then, depending on the risk, create a suicide safety plan that will help the teen or young adult cope with the distress. For more information on how to address suicidality among LGBT youth, please see my previous column (“It does get better... with your help: Preventing suicide,” October 2016, page 30).
Recognize and validate the fears of LGBT youth. Do not dismiss their fears as an overreaction. Because of the adolescent brain’s responsiveness to the limbic system, their fears and emotions are much more intense than are those of adults. Allow them to express how worried they are about the future. Remind them that you are their advocate and that your goal is to keep them safe. Remind your LGBT patients that people who have advocated for them did not disappear overnight because of the election. Some parents of my LGBT patients have pointed out that many LGBT youth feel safer when a nonfamily member advocates for them; therefore, it is essential to remind your LGBT patients about your role as their physician and their advocate.
Another way to support your LGBT patients during this stressful time is to help create a safe environment for them, especially at school. There are some concerns about an increase in antigay and antitrans harassment and bullying since the election.7 Schools are doing their best to respond appropriately to these incidents.8 Fortunately, many schools are responsive to physicians’ recommendations for preventing and addressing school bullying.9 For more information on how providers can address bullying of LGBT youth in school, please refer to my column on bullying (“Bullying,” May 2016, p.1).
Once you reduce the responsiveness of the adolescent brain to the limbic system, you then can focus on the prefrontal cortex to help adolescents engage and cope with their distress. Have them recall from their civics classes that the United States government has checks and balances and that one person does not have unilateral power. Remind the adolescent that administrations and governments do not last forever and that there is an opportunity to change administrations every 4 years.
One of the most powerful ways to engage the prefrontal cortex of the distressed adolescent is to provide the individual with opportunities to be an active member of the community. They can volunteer in many organizations that share their values and beliefs. These organizations do not need to be political, but they should provide some service to the community. This will remind the adolescents that they can have an impact on their own lives and in the lives of others. Volunteering in these organizations will give them a sense of purpose and create a stronger connection to their communities10 – both are antidotes to the intense feeling of despair and hopelessness.
The fear and concerns that LGBT youth have over the election results are intense and deserve attention. Their neurobiology and lack of experience make these fears much more powerful. Providers, parents, and advocates have the responsibility to address these fears, remind LGBT youth that they are their advocates, and remind LGBT youth of the ability to influence the outcomes of their own lives. Providing skills to cope with disappointing outcomes also will prepare LGBT youth for the challenges of adulthood and for the many elections to come.
Resources
AAP: Talking to your children about the election
HealthyChildren.org: How to support your child’s resilience in a time of crisis
Suicide Prevention Lifeline: Patient safety plan template
References
1. “Donald Trump Win Causes Spike in Crisis Support Line Calls,” Time magazine, Nov. 9, 2016.
2. Int Rev Psychiatry. 1992;4(2):177-84.
3. “U.S. Hate Crimes Surge 6%, Fueled by Attacks on Muslims,” the New York Times, Nov. 14, 2016.
4. Arch Suicide Res. 2015;19(3):385-400.
5. “The president of the United States shifted the mainstream in one interview,” Newsweek, May 13, 2012.
6. Neuropsychiatric Disease and Treatment. 2013;9:449-61.
7. “This is Trump’s America: LGBT community fears surge in hate crimes following reports of homophobic attacks,” Salon magazine, Nov. 13, 2016.
8. “School officials grapple with bullying, harassment after election,” Lansing State Journal, Nov. 13, 2016.
9. “Roles for pediatricians in bullying prevention and intervention,” StopBullying.gov, 2016.
10. Adv Psych Treatment. 2014;20(3):217-24.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.
The day after the election, Time magazine reported an increased call volume to the Trevor Project, an organization that provides suicide counseling for LGBT youth.1 A colleague of mine who works closely with the Trevor Project told me that this was the second-highest call volume the organization has received since its inception.
Regardless of your political affiliation, we all can agree that this year’s election was divisive. Many minority groups, including the LGBT community, felt singled out. Although many of us have seen contentious elections in our lifetimes, teenagers, especially LGBT youth, are sensitive to this divisiveness.
Many LGBT youth who called the Trevor Project had expressed fear about the future. Whenever someone becomes suicidal, they have an overwhelming sense of hopelessness.2 Many perceive that the upcoming administration may be hostile to the LGBT community, and because many fear that this new administration may undo all the progress made in LGBT rights in the last 8 years, they have little hope for the future. Numerous reports of increased hate-crime incidents since the start of the election season last year may have exacerbated this feeling of hopelessness.3 This hopelessness may cause many to feel that the best way out is through suicide. Others feel that their sexual orientation or gender identity may be an additional burden to their family during this new era, and so to relieve them of this burden, they consider ending their own lives.4
For adults who have seen many administrations come and go, this may seem like hyperbole. But we have the advantage of living through various elections and administrations, knowing that they were not as catastrophic as others claimed. However, for many LGBT teens or young adults, this is probably their first election after reaching adolescence since Obama was elected in 2008. The Obama administration has been friendly to the LGBT community,5 and for LGBT youth, the upcoming Trump administration may be a substantial departure from this friendliness. In addition, people across the political spectrum have stoked fears among LGBT youth that the new administration will be devastating for the LGBT community. Adolescents, compared with adults, respond more strongly to the limbic system of the brain – the part of the brain involved in emotional processing, which includes fear.6 This fear will override any attempt by the prefrontal cortex – the part of the brain involved in cognitive processing6 – to put the results of this election within context and within perspective. In other words, it is easier for the adolescent brain to become much more despondent over a disappointing outcome.
What can providers do for LGBT youth who feel distressed over the outcome of the election? The approach is twofold. First, address the emotions emanating from the limbic system. Once this influence is dampened, engage the prefrontal cortex to process the emotions and address these fears in a more constructive way.
For LGBT youth who are actively suicidal, providers should first determine the risk for suicide (for example, determine the level of family support, access to lethal means of suicide, etc.) Then, depending on the risk, create a suicide safety plan that will help the teen or young adult cope with the distress. For more information on how to address suicidality among LGBT youth, please see my previous column (“It does get better... with your help: Preventing suicide,” October 2016, page 30).
Recognize and validate the fears of LGBT youth. Do not dismiss their fears as an overreaction. Because of the adolescent brain’s responsiveness to the limbic system, their fears and emotions are much more intense than are those of adults. Allow them to express how worried they are about the future. Remind them that you are their advocate and that your goal is to keep them safe. Remind your LGBT patients that people who have advocated for them did not disappear overnight because of the election. Some parents of my LGBT patients have pointed out that many LGBT youth feel safer when a nonfamily member advocates for them; therefore, it is essential to remind your LGBT patients about your role as their physician and their advocate.
Another way to support your LGBT patients during this stressful time is to help create a safe environment for them, especially at school. There are some concerns about an increase in antigay and antitrans harassment and bullying since the election.7 Schools are doing their best to respond appropriately to these incidents.8 Fortunately, many schools are responsive to physicians’ recommendations for preventing and addressing school bullying.9 For more information on how providers can address bullying of LGBT youth in school, please refer to my column on bullying (“Bullying,” May 2016, p.1).
Once you reduce the responsiveness of the adolescent brain to the limbic system, you then can focus on the prefrontal cortex to help adolescents engage and cope with their distress. Have them recall from their civics classes that the United States government has checks and balances and that one person does not have unilateral power. Remind the adolescent that administrations and governments do not last forever and that there is an opportunity to change administrations every 4 years.
One of the most powerful ways to engage the prefrontal cortex of the distressed adolescent is to provide the individual with opportunities to be an active member of the community. They can volunteer in many organizations that share their values and beliefs. These organizations do not need to be political, but they should provide some service to the community. This will remind the adolescents that they can have an impact on their own lives and in the lives of others. Volunteering in these organizations will give them a sense of purpose and create a stronger connection to their communities10 – both are antidotes to the intense feeling of despair and hopelessness.
The fear and concerns that LGBT youth have over the election results are intense and deserve attention. Their neurobiology and lack of experience make these fears much more powerful. Providers, parents, and advocates have the responsibility to address these fears, remind LGBT youth that they are their advocates, and remind LGBT youth of the ability to influence the outcomes of their own lives. Providing skills to cope with disappointing outcomes also will prepare LGBT youth for the challenges of adulthood and for the many elections to come.
Resources
AAP: Talking to your children about the election
HealthyChildren.org: How to support your child’s resilience in a time of crisis
Suicide Prevention Lifeline: Patient safety plan template
References
1. “Donald Trump Win Causes Spike in Crisis Support Line Calls,” Time magazine, Nov. 9, 2016.
2. Int Rev Psychiatry. 1992;4(2):177-84.
3. “U.S. Hate Crimes Surge 6%, Fueled by Attacks on Muslims,” the New York Times, Nov. 14, 2016.
4. Arch Suicide Res. 2015;19(3):385-400.
5. “The president of the United States shifted the mainstream in one interview,” Newsweek, May 13, 2012.
6. Neuropsychiatric Disease and Treatment. 2013;9:449-61.
7. “This is Trump’s America: LGBT community fears surge in hate crimes following reports of homophobic attacks,” Salon magazine, Nov. 13, 2016.
8. “School officials grapple with bullying, harassment after election,” Lansing State Journal, Nov. 13, 2016.
9. “Roles for pediatricians in bullying prevention and intervention,” StopBullying.gov, 2016.
10. Adv Psych Treatment. 2014;20(3):217-24.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.
The day after the election, Time magazine reported an increased call volume to the Trevor Project, an organization that provides suicide counseling for LGBT youth.1 A colleague of mine who works closely with the Trevor Project told me that this was the second-highest call volume the organization has received since its inception.
Regardless of your political affiliation, we all can agree that this year’s election was divisive. Many minority groups, including the LGBT community, felt singled out. Although many of us have seen contentious elections in our lifetimes, teenagers, especially LGBT youth, are sensitive to this divisiveness.
Many LGBT youth who called the Trevor Project had expressed fear about the future. Whenever someone becomes suicidal, they have an overwhelming sense of hopelessness.2 Many perceive that the upcoming administration may be hostile to the LGBT community, and because many fear that this new administration may undo all the progress made in LGBT rights in the last 8 years, they have little hope for the future. Numerous reports of increased hate-crime incidents since the start of the election season last year may have exacerbated this feeling of hopelessness.3 This hopelessness may cause many to feel that the best way out is through suicide. Others feel that their sexual orientation or gender identity may be an additional burden to their family during this new era, and so to relieve them of this burden, they consider ending their own lives.4
For adults who have seen many administrations come and go, this may seem like hyperbole. But we have the advantage of living through various elections and administrations, knowing that they were not as catastrophic as others claimed. However, for many LGBT teens or young adults, this is probably their first election after reaching adolescence since Obama was elected in 2008. The Obama administration has been friendly to the LGBT community,5 and for LGBT youth, the upcoming Trump administration may be a substantial departure from this friendliness. In addition, people across the political spectrum have stoked fears among LGBT youth that the new administration will be devastating for the LGBT community. Adolescents, compared with adults, respond more strongly to the limbic system of the brain – the part of the brain involved in emotional processing, which includes fear.6 This fear will override any attempt by the prefrontal cortex – the part of the brain involved in cognitive processing6 – to put the results of this election within context and within perspective. In other words, it is easier for the adolescent brain to become much more despondent over a disappointing outcome.
What can providers do for LGBT youth who feel distressed over the outcome of the election? The approach is twofold. First, address the emotions emanating from the limbic system. Once this influence is dampened, engage the prefrontal cortex to process the emotions and address these fears in a more constructive way.
For LGBT youth who are actively suicidal, providers should first determine the risk for suicide (for example, determine the level of family support, access to lethal means of suicide, etc.) Then, depending on the risk, create a suicide safety plan that will help the teen or young adult cope with the distress. For more information on how to address suicidality among LGBT youth, please see my previous column (“It does get better... with your help: Preventing suicide,” October 2016, page 30).
Recognize and validate the fears of LGBT youth. Do not dismiss their fears as an overreaction. Because of the adolescent brain’s responsiveness to the limbic system, their fears and emotions are much more intense than are those of adults. Allow them to express how worried they are about the future. Remind them that you are their advocate and that your goal is to keep them safe. Remind your LGBT patients that people who have advocated for them did not disappear overnight because of the election. Some parents of my LGBT patients have pointed out that many LGBT youth feel safer when a nonfamily member advocates for them; therefore, it is essential to remind your LGBT patients about your role as their physician and their advocate.
Another way to support your LGBT patients during this stressful time is to help create a safe environment for them, especially at school. There are some concerns about an increase in antigay and antitrans harassment and bullying since the election.7 Schools are doing their best to respond appropriately to these incidents.8 Fortunately, many schools are responsive to physicians’ recommendations for preventing and addressing school bullying.9 For more information on how providers can address bullying of LGBT youth in school, please refer to my column on bullying (“Bullying,” May 2016, p.1).
Once you reduce the responsiveness of the adolescent brain to the limbic system, you then can focus on the prefrontal cortex to help adolescents engage and cope with their distress. Have them recall from their civics classes that the United States government has checks and balances and that one person does not have unilateral power. Remind the adolescent that administrations and governments do not last forever and that there is an opportunity to change administrations every 4 years.
One of the most powerful ways to engage the prefrontal cortex of the distressed adolescent is to provide the individual with opportunities to be an active member of the community. They can volunteer in many organizations that share their values and beliefs. These organizations do not need to be political, but they should provide some service to the community. This will remind the adolescents that they can have an impact on their own lives and in the lives of others. Volunteering in these organizations will give them a sense of purpose and create a stronger connection to their communities10 – both are antidotes to the intense feeling of despair and hopelessness.
The fear and concerns that LGBT youth have over the election results are intense and deserve attention. Their neurobiology and lack of experience make these fears much more powerful. Providers, parents, and advocates have the responsibility to address these fears, remind LGBT youth that they are their advocates, and remind LGBT youth of the ability to influence the outcomes of their own lives. Providing skills to cope with disappointing outcomes also will prepare LGBT youth for the challenges of adulthood and for the many elections to come.
Resources
AAP: Talking to your children about the election
HealthyChildren.org: How to support your child’s resilience in a time of crisis
Suicide Prevention Lifeline: Patient safety plan template
References
1. “Donald Trump Win Causes Spike in Crisis Support Line Calls,” Time magazine, Nov. 9, 2016.
2. Int Rev Psychiatry. 1992;4(2):177-84.
3. “U.S. Hate Crimes Surge 6%, Fueled by Attacks on Muslims,” the New York Times, Nov. 14, 2016.
4. Arch Suicide Res. 2015;19(3):385-400.
5. “The president of the United States shifted the mainstream in one interview,” Newsweek, May 13, 2012.
6. Neuropsychiatric Disease and Treatment. 2013;9:449-61.
7. “This is Trump’s America: LGBT community fears surge in hate crimes following reports of homophobic attacks,” Salon magazine, Nov. 13, 2016.
8. “School officials grapple with bullying, harassment after election,” Lansing State Journal, Nov. 13, 2016.
9. “Roles for pediatricians in bullying prevention and intervention,” StopBullying.gov, 2016.
10. Adv Psych Treatment. 2014;20(3):217-24.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.
New research on health-related behaviors of sexual minority youth
The Centers for Disease Control and Prevention released results from the first nationally representative study on health risk behaviors of gay, lesbian, and bisexual (GLB) high school students in August 2016.
These data were collected through the Youth Risk Behavior Survey (YRBS) questionnaire. The YRBS questionnaire was developed in 1990 as a way to monitor health-related behaviors that contribute to the leading causes of mortality and morbidity in youth and young adults. Areas covered by the survey include behaviors related to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, and physical activity. Data are collected every 2 years through national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th-12th grade students.
For the study, sexual minority youth were defined as those who identified as GLB; those who reported sexual contact with members of the same sex only; and those who reported sexual contact with members of both sexes. It is important to note that the YRBS is a school-based survey and does not include youth who do not attend school, for example, homeless and runaway youth.
Exploring and identifying disparities in health behaviors that affect sexual minorities can help us as providers to better target screenings for these health behaviors at the individual level. At the population level, it is important to continue to explore why these differences exist and to continue to develop interventions that help address these differences, while educating families and communities about how to support all of their youth. It is important to note that the majority of sexual minority youth live healthy live; however, this study shows that sexual minority youth do have a higher prevalence of certain health risk behaviors, likely leading to the health disparities we see in this population. Select findings of this study are summarized in the accompanying table.
Continued study is needed to understand the health disparities that occur in sexual minority populations. In October, the National Institutes of Health designated sexual and gender minorities as a specific health disparity population for NIH research. This term encompasses lesbian, gay, bisexual, and transgender individuals as well as any individuals whose sexual identity or gender identity does not align with traditional norms. This hopefully will lead to a growing body of evidence to help all of us learn about the spectrum of sexual and gender identity and better help sexual and gender minority youth reach their full potential.
For more information about the YRBS and the report on health related behaviors in sexual minority youth visit this link:
Selected questionnaire results
Sexual identity
• 88.8% of students identified as heterosexual.
• 6.0% identified as bisexual.
• 3.2% were not sure.
• 2.0% identified as gay or lesbian.
Sexual behaviors
• 48% had had sexual contact with the opposite sex only.
• 4.6% had sexual contact with both sexes.
• 1.7% had had sexual contact with the same sex only.
• 45.7% had no sexual contact.
Mental health
Percent of students who reported making a suicide plan in the 12 months preceding the survey:
• 11.9% of heterosexual students.
• 27.9% of students not sure of sexual identity.
• 38.2% of gay, lesbian, bisexual (GLB) students.
Percent of students who attempted suicide in the 12 months preceding the survey:
• 6.4% of heterosexual students.
• 13.7% of students not sure of sexual identity.
• 29.4% of GLB students.
Sexual Behaviors
First sex before the age of 13:
• 3.4% of heterosexual students.
• 8.8% of students not sure of their sexual identity.
• 7.3% of GLB students.
Drank alcohol or used drugs before last sex:
• 20.0% of heterosexual students.
• 44.5% of students not sure of their sexual identity.
• 22.4% of GLB students.
Tested for HIV:
• 9.3% of heterosexual students.
• 12.8% of students not sure of their sexual identity.
• 18.2% of GLB students.
Substance use
Currently smoking cigarettes daily:
• 1.9% of heterosexual students.
• 7.0% of students not sure of their sexual identity.
• 4.0% of GLB students.
Current alcohol use:
• 32.1% of heterosexual students.
• 34.6% of students not sure of their sexual identity.
• 40.5% of GLB students.
Current marijuana use:
• 20.7% of heterosexual students.
• 26.0% of students not sure of their sexual identity.
• 32.0% of GLB students.
Used hallucinogenic drugs (such as LSD, acid, PCP, angel dust, mescaline, or mushrooms):
• 5.5% of heterosexual students.
• 15.7% of students not sure of their sexual identity.
• 11.5% of GLB students.
Ever used heroin:
• 1.3% of heterosexual students.
• 9.3% of students not sure of their sexual identity.
• 6.0% of GLB students.
Ever took prescription drugs without a doctor’s prescription:
15.5% of heterosexual students.
24.3% of students not sure of their sexual identity.
27.5% of GLB students.
Physical Activity
Did not participate in at least 60 minutes of physical activity on at least 1 day in past week:
• 12.6% of heterosexual students.
• 27.0% of students not sure of their sexual identity.
• 25.7% of GLB students.
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.
The Centers for Disease Control and Prevention released results from the first nationally representative study on health risk behaviors of gay, lesbian, and bisexual (GLB) high school students in August 2016.
These data were collected through the Youth Risk Behavior Survey (YRBS) questionnaire. The YRBS questionnaire was developed in 1990 as a way to monitor health-related behaviors that contribute to the leading causes of mortality and morbidity in youth and young adults. Areas covered by the survey include behaviors related to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, and physical activity. Data are collected every 2 years through national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th-12th grade students.
For the study, sexual minority youth were defined as those who identified as GLB; those who reported sexual contact with members of the same sex only; and those who reported sexual contact with members of both sexes. It is important to note that the YRBS is a school-based survey and does not include youth who do not attend school, for example, homeless and runaway youth.
Exploring and identifying disparities in health behaviors that affect sexual minorities can help us as providers to better target screenings for these health behaviors at the individual level. At the population level, it is important to continue to explore why these differences exist and to continue to develop interventions that help address these differences, while educating families and communities about how to support all of their youth. It is important to note that the majority of sexual minority youth live healthy live; however, this study shows that sexual minority youth do have a higher prevalence of certain health risk behaviors, likely leading to the health disparities we see in this population. Select findings of this study are summarized in the accompanying table.
Continued study is needed to understand the health disparities that occur in sexual minority populations. In October, the National Institutes of Health designated sexual and gender minorities as a specific health disparity population for NIH research. This term encompasses lesbian, gay, bisexual, and transgender individuals as well as any individuals whose sexual identity or gender identity does not align with traditional norms. This hopefully will lead to a growing body of evidence to help all of us learn about the spectrum of sexual and gender identity and better help sexual and gender minority youth reach their full potential.
For more information about the YRBS and the report on health related behaviors in sexual minority youth visit this link:
Selected questionnaire results
Sexual identity
• 88.8% of students identified as heterosexual.
• 6.0% identified as bisexual.
• 3.2% were not sure.
• 2.0% identified as gay or lesbian.
Sexual behaviors
• 48% had had sexual contact with the opposite sex only.
• 4.6% had sexual contact with both sexes.
• 1.7% had had sexual contact with the same sex only.
• 45.7% had no sexual contact.
Mental health
Percent of students who reported making a suicide plan in the 12 months preceding the survey:
• 11.9% of heterosexual students.
• 27.9% of students not sure of sexual identity.
• 38.2% of gay, lesbian, bisexual (GLB) students.
Percent of students who attempted suicide in the 12 months preceding the survey:
• 6.4% of heterosexual students.
• 13.7% of students not sure of sexual identity.
• 29.4% of GLB students.
Sexual Behaviors
First sex before the age of 13:
• 3.4% of heterosexual students.
• 8.8% of students not sure of their sexual identity.
• 7.3% of GLB students.
Drank alcohol or used drugs before last sex:
• 20.0% of heterosexual students.
• 44.5% of students not sure of their sexual identity.
• 22.4% of GLB students.
Tested for HIV:
• 9.3% of heterosexual students.
• 12.8% of students not sure of their sexual identity.
• 18.2% of GLB students.
Substance use
Currently smoking cigarettes daily:
• 1.9% of heterosexual students.
• 7.0% of students not sure of their sexual identity.
• 4.0% of GLB students.
Current alcohol use:
• 32.1% of heterosexual students.
• 34.6% of students not sure of their sexual identity.
• 40.5% of GLB students.
Current marijuana use:
• 20.7% of heterosexual students.
• 26.0% of students not sure of their sexual identity.
• 32.0% of GLB students.
Used hallucinogenic drugs (such as LSD, acid, PCP, angel dust, mescaline, or mushrooms):
• 5.5% of heterosexual students.
• 15.7% of students not sure of their sexual identity.
• 11.5% of GLB students.
Ever used heroin:
• 1.3% of heterosexual students.
• 9.3% of students not sure of their sexual identity.
• 6.0% of GLB students.
Ever took prescription drugs without a doctor’s prescription:
15.5% of heterosexual students.
24.3% of students not sure of their sexual identity.
27.5% of GLB students.
Physical Activity
Did not participate in at least 60 minutes of physical activity on at least 1 day in past week:
• 12.6% of heterosexual students.
• 27.0% of students not sure of their sexual identity.
• 25.7% of GLB students.
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.
The Centers for Disease Control and Prevention released results from the first nationally representative study on health risk behaviors of gay, lesbian, and bisexual (GLB) high school students in August 2016.
These data were collected through the Youth Risk Behavior Survey (YRBS) questionnaire. The YRBS questionnaire was developed in 1990 as a way to monitor health-related behaviors that contribute to the leading causes of mortality and morbidity in youth and young adults. Areas covered by the survey include behaviors related to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, and physical activity. Data are collected every 2 years through national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th-12th grade students.
For the study, sexual minority youth were defined as those who identified as GLB; those who reported sexual contact with members of the same sex only; and those who reported sexual contact with members of both sexes. It is important to note that the YRBS is a school-based survey and does not include youth who do not attend school, for example, homeless and runaway youth.
Exploring and identifying disparities in health behaviors that affect sexual minorities can help us as providers to better target screenings for these health behaviors at the individual level. At the population level, it is important to continue to explore why these differences exist and to continue to develop interventions that help address these differences, while educating families and communities about how to support all of their youth. It is important to note that the majority of sexual minority youth live healthy live; however, this study shows that sexual minority youth do have a higher prevalence of certain health risk behaviors, likely leading to the health disparities we see in this population. Select findings of this study are summarized in the accompanying table.
Continued study is needed to understand the health disparities that occur in sexual minority populations. In October, the National Institutes of Health designated sexual and gender minorities as a specific health disparity population for NIH research. This term encompasses lesbian, gay, bisexual, and transgender individuals as well as any individuals whose sexual identity or gender identity does not align with traditional norms. This hopefully will lead to a growing body of evidence to help all of us learn about the spectrum of sexual and gender identity and better help sexual and gender minority youth reach their full potential.
For more information about the YRBS and the report on health related behaviors in sexual minority youth visit this link:
Selected questionnaire results
Sexual identity
• 88.8% of students identified as heterosexual.
• 6.0% identified as bisexual.
• 3.2% were not sure.
• 2.0% identified as gay or lesbian.
Sexual behaviors
• 48% had had sexual contact with the opposite sex only.
• 4.6% had sexual contact with both sexes.
• 1.7% had had sexual contact with the same sex only.
• 45.7% had no sexual contact.
Mental health
Percent of students who reported making a suicide plan in the 12 months preceding the survey:
• 11.9% of heterosexual students.
• 27.9% of students not sure of sexual identity.
• 38.2% of gay, lesbian, bisexual (GLB) students.
Percent of students who attempted suicide in the 12 months preceding the survey:
• 6.4% of heterosexual students.
• 13.7% of students not sure of sexual identity.
• 29.4% of GLB students.
Sexual Behaviors
First sex before the age of 13:
• 3.4% of heterosexual students.
• 8.8% of students not sure of their sexual identity.
• 7.3% of GLB students.
Drank alcohol or used drugs before last sex:
• 20.0% of heterosexual students.
• 44.5% of students not sure of their sexual identity.
• 22.4% of GLB students.
Tested for HIV:
• 9.3% of heterosexual students.
• 12.8% of students not sure of their sexual identity.
• 18.2% of GLB students.
Substance use
Currently smoking cigarettes daily:
• 1.9% of heterosexual students.
• 7.0% of students not sure of their sexual identity.
• 4.0% of GLB students.
Current alcohol use:
• 32.1% of heterosexual students.
• 34.6% of students not sure of their sexual identity.
• 40.5% of GLB students.
Current marijuana use:
• 20.7% of heterosexual students.
• 26.0% of students not sure of their sexual identity.
• 32.0% of GLB students.
Used hallucinogenic drugs (such as LSD, acid, PCP, angel dust, mescaline, or mushrooms):
• 5.5% of heterosexual students.
• 15.7% of students not sure of their sexual identity.
• 11.5% of GLB students.
Ever used heroin:
• 1.3% of heterosexual students.
• 9.3% of students not sure of their sexual identity.
• 6.0% of GLB students.
Ever took prescription drugs without a doctor’s prescription:
15.5% of heterosexual students.
24.3% of students not sure of their sexual identity.
27.5% of GLB students.
Physical Activity
Did not participate in at least 60 minutes of physical activity on at least 1 day in past week:
• 12.6% of heterosexual students.
• 27.0% of students not sure of their sexual identity.
• 25.7% of GLB students.
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.
It does get better ... with your help: Preventing suicide
Suicide continues to be a major public health problem in the United States. It is the second leading cause of death in young people aged 10-24 years, according to 2010 injury data from the Centers from Disease Control and Prevention.1 This problem disproportionately affects lesbian, gay, bisexual, and transgender (LGBT) youth. Compared to their heterosexual peers, LGBT youth are four times as likely to attempt suicide.2 In addition, almost 50% of transgender youth have attempted suicide.3
Why are LGBT youth at high risk for suicide? Antigay and antitrans stigma and discrimination against LGBT youth create a very stressful environment. For example, LGBT youth are two times more likely than are heterosexual youth to experience bullying4 because of their sexual orientation, and half of transgender youth have reported bullying because of their gender identity.3 LGBT youth tend to perceive lower levels of parental support than do heterosexual youth.5-8 A combination of harassment from peers and decreased perceived support from families increases the risk for suicide in LGBT youth.
However, there are factors that can reduce this risk. LGBT youth whose parents reject their sexual orientation or gender identity are eight times as likely to be suicidal,3,9 while in contrast, LGBT youth whose parents are more accepting are less likely to be suicidal.10 These studies underscore the importance of social support in reducing the stress from antigay and antitrans discrimination, and therefore, play a role in preventing suicide.
Health care providers are another source of support for LGBT youth. They can play a role in providing education and preventing suicide in this population because many victims of suicide have visited a health care provider before attempting to kill themselves.11 It is important for providers to screen for suicide in their patients. Although there is no lab test for suicidal ideation, suicidal adolescents tend to have certain risk factors. In addition to being LGBT, being bullied, and having a lack of social support, other risk factors are psychiatric illness, a history of being impulsive, alcohol and substance abuse, and most important of all, a previous suicide attempt.12
When screening for suicide risk, always remember that at the beginning of any visit with an adolescent, remind them about confidentiality and its limits (e.g., breaking confidentiality if the patient is suicidal). Although this appears counterintuitive, it actually builds rapport between you and the patient. If you don’t discuss the limits of confidentiality beforehand and have to break it because the patient is suicidal, the patient is less likely to tell you again in the future. Once you suspect suicidal ideation based on the above risk factors, you can ask:
• Have you thought about ending your own life or would you rather be dead?
• Have you done something to harm yourself or to end your life?
• Have you considered ways to end your own life?12
Some clinicians have expressed concern over asking about suicide in their adolescent patients, but doing so does not induce suicidal thoughts.13 If a patient does express any of the above, the clinician must then inquire about other risk factors that increase the individual’s chances of completing suicide. The American Association of Suicidology has listed several warning signs of imminent suicide, which can be remembered with the acronym IS PATH WARM. This stands for Ideation, Substance use, Purposelessness, heightened Anxiety, feeling Trapped, feeling Hopeless, Withdrawal from friends and family, uncontrollable Anger, engaging in Reckless behavior, and dramatic Mood changes.14
If a patient threatens to kill him/herself, has a specific plan to do so, or speaks about death and suicide, then the clinician must act immediately. Although sending a patient to the emergency department is the safest option, it is not the only option. If a good support system is present, and the patient lives in an environment where he or she does not have the means to carry out a suicide (e.g., there are no guns in the home), then the clinician can create a safety plan for the patient. A safety plan is different from a “no suicide contract.” A no suicide contract is a written commitment that the patient does not engage in suicidal behavior. Many experts caution against a no suicide contract because it can create a false sense of security for the clinician and does not address the strategies needed to combat feelings of suicidality.15,16
Usually with a safety plan, the clinician and the patient identify several people the patient can contact if the patient feels suicidal. In addition, the clinician and the patient can discuss ways the patient can cope with his/her feelings or distract himself/herself from suicidal thoughts (e.g., going out for a walk, watching a movie, etc.). Finally, if these methods fail, patients are provided with emergency hotlines or directed to the emergency department. The Suicide Prevention Resource Center has a template of a patient safety plan.
Finally, clinicians should be proactive in preventing suicide, especially for LGBT youth. Because bullying is a risk factor for suicide, and because LGBT youth are disproportionately affected by bullying, clinicians should advocate for antibullying school policies and advocate for schools to be more LGBT friendly. Clinicians also should speak to the community about suicide, its warning signs, and how to address it. Just like with any disease, prevention is the most effective form of treatment.
As clinicians, we should always be on the lookout for suicide in our young patients, especially LGBT youth. For many LGBT youth, we may be the only source of support. If patients are suicidal, we should work with them to determine how to keep the them safe. We have a powerful voice in the community. We can advocate for making schools safe for LGBT youth and educate the community in suicide prevention. Such a powerful voice proclaiming that it gets better can save a life.
Resources
• The Trevor Project: A non-profit organization dedicated to prevent suicide in LGBT Youth (www.thetrevorproject.org)
• It Gets Better Project: Another website dedicated to preventing suicide in LGBT youth by promoting the message that life will improve for LGBT teens (www.itgetsbetter.org)
• Patient Safety Plan Template from the Suicide Prevention Resource Center (www.sprc.org)
References
1. CDC. NCIPC. Web-based Injury Statistics Query and Reporting System (WISQARS). 2010.
2. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.
3. 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).
4. J Adolesc Health. 2014 Sep;55(3):432-8.
5. J Youth Adolesc. 2013 Mar;42(3):376-93.
6. J Youth Adolesc. 2010 Oct;39(10):1189-98.
7. School Psychology Review. 2008;37(2):202-16.
8. J Homosex. 2010;57(2):287-309.
9. Pediatrics. 2009 Jan;123(1):346-52.
10. J Child Adolesc Psychiatr Nurs. 2010 Nov;23(4):205-13.
11. Mayo Clin Proc. 2011 Aug;86(8):792-800.
12. Ital J Pediatr. 2015 Jul 7;41:49.
13. Ment Health Fam Med. 2008 Dec;5(4):229-35.
14. Know the Warning Signs of Suicide. American Association of Suicidology.
15. J Psychiatr Ment Health Nurs. 2008 Aug;15(6):512-22.
16. J Amer Acad Psych Law. 1999;27(3):445-50.
Dr. Montano is a physician at Children’s Hospital of Pittsburgh of UPMC and a clinical instructor of pediatrics at the University of Pittsburgh School of Medicine.
Suicide continues to be a major public health problem in the United States. It is the second leading cause of death in young people aged 10-24 years, according to 2010 injury data from the Centers from Disease Control and Prevention.1 This problem disproportionately affects lesbian, gay, bisexual, and transgender (LGBT) youth. Compared to their heterosexual peers, LGBT youth are four times as likely to attempt suicide.2 In addition, almost 50% of transgender youth have attempted suicide.3
Why are LGBT youth at high risk for suicide? Antigay and antitrans stigma and discrimination against LGBT youth create a very stressful environment. For example, LGBT youth are two times more likely than are heterosexual youth to experience bullying4 because of their sexual orientation, and half of transgender youth have reported bullying because of their gender identity.3 LGBT youth tend to perceive lower levels of parental support than do heterosexual youth.5-8 A combination of harassment from peers and decreased perceived support from families increases the risk for suicide in LGBT youth.
However, there are factors that can reduce this risk. LGBT youth whose parents reject their sexual orientation or gender identity are eight times as likely to be suicidal,3,9 while in contrast, LGBT youth whose parents are more accepting are less likely to be suicidal.10 These studies underscore the importance of social support in reducing the stress from antigay and antitrans discrimination, and therefore, play a role in preventing suicide.
Health care providers are another source of support for LGBT youth. They can play a role in providing education and preventing suicide in this population because many victims of suicide have visited a health care provider before attempting to kill themselves.11 It is important for providers to screen for suicide in their patients. Although there is no lab test for suicidal ideation, suicidal adolescents tend to have certain risk factors. In addition to being LGBT, being bullied, and having a lack of social support, other risk factors are psychiatric illness, a history of being impulsive, alcohol and substance abuse, and most important of all, a previous suicide attempt.12
When screening for suicide risk, always remember that at the beginning of any visit with an adolescent, remind them about confidentiality and its limits (e.g., breaking confidentiality if the patient is suicidal). Although this appears counterintuitive, it actually builds rapport between you and the patient. If you don’t discuss the limits of confidentiality beforehand and have to break it because the patient is suicidal, the patient is less likely to tell you again in the future. Once you suspect suicidal ideation based on the above risk factors, you can ask:
• Have you thought about ending your own life or would you rather be dead?
• Have you done something to harm yourself or to end your life?
• Have you considered ways to end your own life?12
Some clinicians have expressed concern over asking about suicide in their adolescent patients, but doing so does not induce suicidal thoughts.13 If a patient does express any of the above, the clinician must then inquire about other risk factors that increase the individual’s chances of completing suicide. The American Association of Suicidology has listed several warning signs of imminent suicide, which can be remembered with the acronym IS PATH WARM. This stands for Ideation, Substance use, Purposelessness, heightened Anxiety, feeling Trapped, feeling Hopeless, Withdrawal from friends and family, uncontrollable Anger, engaging in Reckless behavior, and dramatic Mood changes.14
If a patient threatens to kill him/herself, has a specific plan to do so, or speaks about death and suicide, then the clinician must act immediately. Although sending a patient to the emergency department is the safest option, it is not the only option. If a good support system is present, and the patient lives in an environment where he or she does not have the means to carry out a suicide (e.g., there are no guns in the home), then the clinician can create a safety plan for the patient. A safety plan is different from a “no suicide contract.” A no suicide contract is a written commitment that the patient does not engage in suicidal behavior. Many experts caution against a no suicide contract because it can create a false sense of security for the clinician and does not address the strategies needed to combat feelings of suicidality.15,16
Usually with a safety plan, the clinician and the patient identify several people the patient can contact if the patient feels suicidal. In addition, the clinician and the patient can discuss ways the patient can cope with his/her feelings or distract himself/herself from suicidal thoughts (e.g., going out for a walk, watching a movie, etc.). Finally, if these methods fail, patients are provided with emergency hotlines or directed to the emergency department. The Suicide Prevention Resource Center has a template of a patient safety plan.
Finally, clinicians should be proactive in preventing suicide, especially for LGBT youth. Because bullying is a risk factor for suicide, and because LGBT youth are disproportionately affected by bullying, clinicians should advocate for antibullying school policies and advocate for schools to be more LGBT friendly. Clinicians also should speak to the community about suicide, its warning signs, and how to address it. Just like with any disease, prevention is the most effective form of treatment.
As clinicians, we should always be on the lookout for suicide in our young patients, especially LGBT youth. For many LGBT youth, we may be the only source of support. If patients are suicidal, we should work with them to determine how to keep the them safe. We have a powerful voice in the community. We can advocate for making schools safe for LGBT youth and educate the community in suicide prevention. Such a powerful voice proclaiming that it gets better can save a life.
Resources
• The Trevor Project: A non-profit organization dedicated to prevent suicide in LGBT Youth (www.thetrevorproject.org)
• It Gets Better Project: Another website dedicated to preventing suicide in LGBT youth by promoting the message that life will improve for LGBT teens (www.itgetsbetter.org)
• Patient Safety Plan Template from the Suicide Prevention Resource Center (www.sprc.org)
References
1. CDC. NCIPC. Web-based Injury Statistics Query and Reporting System (WISQARS). 2010.
2. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.
3. 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).
4. J Adolesc Health. 2014 Sep;55(3):432-8.
5. J Youth Adolesc. 2013 Mar;42(3):376-93.
6. J Youth Adolesc. 2010 Oct;39(10):1189-98.
7. School Psychology Review. 2008;37(2):202-16.
8. J Homosex. 2010;57(2):287-309.
9. Pediatrics. 2009 Jan;123(1):346-52.
10. J Child Adolesc Psychiatr Nurs. 2010 Nov;23(4):205-13.
11. Mayo Clin Proc. 2011 Aug;86(8):792-800.
12. Ital J Pediatr. 2015 Jul 7;41:49.
13. Ment Health Fam Med. 2008 Dec;5(4):229-35.
14. Know the Warning Signs of Suicide. American Association of Suicidology.
15. J Psychiatr Ment Health Nurs. 2008 Aug;15(6):512-22.
16. J Amer Acad Psych Law. 1999;27(3):445-50.
Dr. Montano is a physician at Children’s Hospital of Pittsburgh of UPMC and a clinical instructor of pediatrics at the University of Pittsburgh School of Medicine.
Suicide continues to be a major public health problem in the United States. It is the second leading cause of death in young people aged 10-24 years, according to 2010 injury data from the Centers from Disease Control and Prevention.1 This problem disproportionately affects lesbian, gay, bisexual, and transgender (LGBT) youth. Compared to their heterosexual peers, LGBT youth are four times as likely to attempt suicide.2 In addition, almost 50% of transgender youth have attempted suicide.3
Why are LGBT youth at high risk for suicide? Antigay and antitrans stigma and discrimination against LGBT youth create a very stressful environment. For example, LGBT youth are two times more likely than are heterosexual youth to experience bullying4 because of their sexual orientation, and half of transgender youth have reported bullying because of their gender identity.3 LGBT youth tend to perceive lower levels of parental support than do heterosexual youth.5-8 A combination of harassment from peers and decreased perceived support from families increases the risk for suicide in LGBT youth.
However, there are factors that can reduce this risk. LGBT youth whose parents reject their sexual orientation or gender identity are eight times as likely to be suicidal,3,9 while in contrast, LGBT youth whose parents are more accepting are less likely to be suicidal.10 These studies underscore the importance of social support in reducing the stress from antigay and antitrans discrimination, and therefore, play a role in preventing suicide.
Health care providers are another source of support for LGBT youth. They can play a role in providing education and preventing suicide in this population because many victims of suicide have visited a health care provider before attempting to kill themselves.11 It is important for providers to screen for suicide in their patients. Although there is no lab test for suicidal ideation, suicidal adolescents tend to have certain risk factors. In addition to being LGBT, being bullied, and having a lack of social support, other risk factors are psychiatric illness, a history of being impulsive, alcohol and substance abuse, and most important of all, a previous suicide attempt.12
When screening for suicide risk, always remember that at the beginning of any visit with an adolescent, remind them about confidentiality and its limits (e.g., breaking confidentiality if the patient is suicidal). Although this appears counterintuitive, it actually builds rapport between you and the patient. If you don’t discuss the limits of confidentiality beforehand and have to break it because the patient is suicidal, the patient is less likely to tell you again in the future. Once you suspect suicidal ideation based on the above risk factors, you can ask:
• Have you thought about ending your own life or would you rather be dead?
• Have you done something to harm yourself or to end your life?
• Have you considered ways to end your own life?12
Some clinicians have expressed concern over asking about suicide in their adolescent patients, but doing so does not induce suicidal thoughts.13 If a patient does express any of the above, the clinician must then inquire about other risk factors that increase the individual’s chances of completing suicide. The American Association of Suicidology has listed several warning signs of imminent suicide, which can be remembered with the acronym IS PATH WARM. This stands for Ideation, Substance use, Purposelessness, heightened Anxiety, feeling Trapped, feeling Hopeless, Withdrawal from friends and family, uncontrollable Anger, engaging in Reckless behavior, and dramatic Mood changes.14
If a patient threatens to kill him/herself, has a specific plan to do so, or speaks about death and suicide, then the clinician must act immediately. Although sending a patient to the emergency department is the safest option, it is not the only option. If a good support system is present, and the patient lives in an environment where he or she does not have the means to carry out a suicide (e.g., there are no guns in the home), then the clinician can create a safety plan for the patient. A safety plan is different from a “no suicide contract.” A no suicide contract is a written commitment that the patient does not engage in suicidal behavior. Many experts caution against a no suicide contract because it can create a false sense of security for the clinician and does not address the strategies needed to combat feelings of suicidality.15,16
Usually with a safety plan, the clinician and the patient identify several people the patient can contact if the patient feels suicidal. In addition, the clinician and the patient can discuss ways the patient can cope with his/her feelings or distract himself/herself from suicidal thoughts (e.g., going out for a walk, watching a movie, etc.). Finally, if these methods fail, patients are provided with emergency hotlines or directed to the emergency department. The Suicide Prevention Resource Center has a template of a patient safety plan.
Finally, clinicians should be proactive in preventing suicide, especially for LGBT youth. Because bullying is a risk factor for suicide, and because LGBT youth are disproportionately affected by bullying, clinicians should advocate for antibullying school policies and advocate for schools to be more LGBT friendly. Clinicians also should speak to the community about suicide, its warning signs, and how to address it. Just like with any disease, prevention is the most effective form of treatment.
As clinicians, we should always be on the lookout for suicide in our young patients, especially LGBT youth. For many LGBT youth, we may be the only source of support. If patients are suicidal, we should work with them to determine how to keep the them safe. We have a powerful voice in the community. We can advocate for making schools safe for LGBT youth and educate the community in suicide prevention. Such a powerful voice proclaiming that it gets better can save a life.
Resources
• The Trevor Project: A non-profit organization dedicated to prevent suicide in LGBT Youth (www.thetrevorproject.org)
• It Gets Better Project: Another website dedicated to preventing suicide in LGBT youth by promoting the message that life will improve for LGBT teens (www.itgetsbetter.org)
• Patient Safety Plan Template from the Suicide Prevention Resource Center (www.sprc.org)
References
1. CDC. NCIPC. Web-based Injury Statistics Query and Reporting System (WISQARS). 2010.
2. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.
3. 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).
4. J Adolesc Health. 2014 Sep;55(3):432-8.
5. J Youth Adolesc. 2013 Mar;42(3):376-93.
6. J Youth Adolesc. 2010 Oct;39(10):1189-98.
7. School Psychology Review. 2008;37(2):202-16.
8. J Homosex. 2010;57(2):287-309.
9. Pediatrics. 2009 Jan;123(1):346-52.
10. J Child Adolesc Psychiatr Nurs. 2010 Nov;23(4):205-13.
11. Mayo Clin Proc. 2011 Aug;86(8):792-800.
12. Ital J Pediatr. 2015 Jul 7;41:49.
13. Ment Health Fam Med. 2008 Dec;5(4):229-35.
14. Know the Warning Signs of Suicide. American Association of Suicidology.
15. J Psychiatr Ment Health Nurs. 2008 Aug;15(6):512-22.
16. J Amer Acad Psych Law. 1999;27(3):445-50.
Dr. Montano is a physician at Children’s Hospital of Pittsburgh of UPMC and a clinical instructor of pediatrics at the University of Pittsburgh School of Medicine.
How we can support our LGBTQ patients
This past month has been a difficult one. The violence committed against people on the basis of presumed sexual orientation, color of skin, religion, and occupation has been difficult to make sense of. These tragic and horrible events highlight the continued need to focus on building inclusive environments and fostering communication between people with different backgrounds, points of view, and life experiences.
Several of my past articles have touched on the need to create inclusive environments for our LGBTQ (lesbian, gay, bisexual, transgender, questioning) patients, but have not included direct input from youth. With this in mind, I sat down with several youth from our local youth LGBTQ center in Ohio to ask them how we as health care providers could be more supportive of our patients.
Here are some of their suggestions:
• “Trust your patients. … Respect that I am knowledgeable about my body.”
Youth in the group stated that they want providers who listen to and trust what they say. Youth reported that they trust that their medical providers are experts in medicine and the care of patients, but they are the experts on themselves.
• “Don’t blame the hormones. Don’t blame things on puberty. … It’s not just a phase.”
Youth reported that they often get frustrated when providers assume that their sexual orientation or gender identity is “just a phase.” While adolescence can be a time of experimentation, it is important to acknowledge and respect youth’s emerging identities.
• “Know your patients. Educate yourselves.”
Many youth reported that while they are happy to share their stories, they do not want to be put in the role of having to educate their providers about the basics.
Youth expect that their providers have a general understanding of LGBTQ terminology and health care needs. They are happy to answer specific questions, but expect a degree of cultural competency from their providers.
• “Don’t push birth control. Don’t make assumptions about my behaviors; ask me first.”
Many female-bodied youth had the perception that providers make assumptions about their sexual orientation (assuming they are heterosexual), sexual behaviors, and risk of unintended pregnancy and sexually transmitted diseases.
Youth reported that they are open to conversations about reproductive health and safe sex, but get turned off when providers incorrectly assume they are heterosexual and in need of birth control. Asking about sexual attraction and the gender of partners as a routine part of any adolescent sexual history can help providers avoid these mistakes.
• “Have a discussion versus telling people what to do. Tell me why you are checking things and what they mean.”
Youth reported that they were interested in being active participants in their health care visits. They stated that if labs are being checked, they want to know why and what the results mean. When medications are prescribed or lifestyle changes are recommended, they want to discuss why these changes are necessary and have some input as to how these changes happen.
• “I like to have my privacy respected. It can be uncomfortable talking about things with my parents in the room.”
Many youth reported privacy and one-on-one time with their providers being important. They reported being uncomfortable or embarrassed talking about certain topics in front of their parents and valued providers who respected their privacy.
Private time with patients is not meant to cut parents out of the visit; rather it is meant to be a time when patients can openly discuss concerns with their providers and begin to take ownership of their health and bodies.
Many of the suggestions above are helpful in the care of all youth, regardless of sexual orientation and gender identity. Most of the qualities youth were looking for in providers were related to communication and respect and are in keeping with current research and guidelines on creating youth friendly services. Following these suggestions, and continuing to find ways to include youth in our conversations to improve health care, are just a few ways we can make youth feel more comfortable in this setting and hopefully begin to achieve health equity for all youth.
Acknowledgments
I appreciate the youth at Kaleidoscope Youth Center for giving their time and continually helping me improve the care I provide to all patients and allowing me to share this information with others.
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.
This past month has been a difficult one. The violence committed against people on the basis of presumed sexual orientation, color of skin, religion, and occupation has been difficult to make sense of. These tragic and horrible events highlight the continued need to focus on building inclusive environments and fostering communication between people with different backgrounds, points of view, and life experiences.
Several of my past articles have touched on the need to create inclusive environments for our LGBTQ (lesbian, gay, bisexual, transgender, questioning) patients, but have not included direct input from youth. With this in mind, I sat down with several youth from our local youth LGBTQ center in Ohio to ask them how we as health care providers could be more supportive of our patients.
Here are some of their suggestions:
• “Trust your patients. … Respect that I am knowledgeable about my body.”
Youth in the group stated that they want providers who listen to and trust what they say. Youth reported that they trust that their medical providers are experts in medicine and the care of patients, but they are the experts on themselves.
• “Don’t blame the hormones. Don’t blame things on puberty. … It’s not just a phase.”
Youth reported that they often get frustrated when providers assume that their sexual orientation or gender identity is “just a phase.” While adolescence can be a time of experimentation, it is important to acknowledge and respect youth’s emerging identities.
• “Know your patients. Educate yourselves.”
Many youth reported that while they are happy to share their stories, they do not want to be put in the role of having to educate their providers about the basics.
Youth expect that their providers have a general understanding of LGBTQ terminology and health care needs. They are happy to answer specific questions, but expect a degree of cultural competency from their providers.
• “Don’t push birth control. Don’t make assumptions about my behaviors; ask me first.”
Many female-bodied youth had the perception that providers make assumptions about their sexual orientation (assuming they are heterosexual), sexual behaviors, and risk of unintended pregnancy and sexually transmitted diseases.
Youth reported that they are open to conversations about reproductive health and safe sex, but get turned off when providers incorrectly assume they are heterosexual and in need of birth control. Asking about sexual attraction and the gender of partners as a routine part of any adolescent sexual history can help providers avoid these mistakes.
• “Have a discussion versus telling people what to do. Tell me why you are checking things and what they mean.”
Youth reported that they were interested in being active participants in their health care visits. They stated that if labs are being checked, they want to know why and what the results mean. When medications are prescribed or lifestyle changes are recommended, they want to discuss why these changes are necessary and have some input as to how these changes happen.
• “I like to have my privacy respected. It can be uncomfortable talking about things with my parents in the room.”
Many youth reported privacy and one-on-one time with their providers being important. They reported being uncomfortable or embarrassed talking about certain topics in front of their parents and valued providers who respected their privacy.
Private time with patients is not meant to cut parents out of the visit; rather it is meant to be a time when patients can openly discuss concerns with their providers and begin to take ownership of their health and bodies.
Many of the suggestions above are helpful in the care of all youth, regardless of sexual orientation and gender identity. Most of the qualities youth were looking for in providers were related to communication and respect and are in keeping with current research and guidelines on creating youth friendly services. Following these suggestions, and continuing to find ways to include youth in our conversations to improve health care, are just a few ways we can make youth feel more comfortable in this setting and hopefully begin to achieve health equity for all youth.
Acknowledgments
I appreciate the youth at Kaleidoscope Youth Center for giving their time and continually helping me improve the care I provide to all patients and allowing me to share this information with others.
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.
This past month has been a difficult one. The violence committed against people on the basis of presumed sexual orientation, color of skin, religion, and occupation has been difficult to make sense of. These tragic and horrible events highlight the continued need to focus on building inclusive environments and fostering communication between people with different backgrounds, points of view, and life experiences.
Several of my past articles have touched on the need to create inclusive environments for our LGBTQ (lesbian, gay, bisexual, transgender, questioning) patients, but have not included direct input from youth. With this in mind, I sat down with several youth from our local youth LGBTQ center in Ohio to ask them how we as health care providers could be more supportive of our patients.
Here are some of their suggestions:
• “Trust your patients. … Respect that I am knowledgeable about my body.”
Youth in the group stated that they want providers who listen to and trust what they say. Youth reported that they trust that their medical providers are experts in medicine and the care of patients, but they are the experts on themselves.
• “Don’t blame the hormones. Don’t blame things on puberty. … It’s not just a phase.”
Youth reported that they often get frustrated when providers assume that their sexual orientation or gender identity is “just a phase.” While adolescence can be a time of experimentation, it is important to acknowledge and respect youth’s emerging identities.
• “Know your patients. Educate yourselves.”
Many youth reported that while they are happy to share their stories, they do not want to be put in the role of having to educate their providers about the basics.
Youth expect that their providers have a general understanding of LGBTQ terminology and health care needs. They are happy to answer specific questions, but expect a degree of cultural competency from their providers.
• “Don’t push birth control. Don’t make assumptions about my behaviors; ask me first.”
Many female-bodied youth had the perception that providers make assumptions about their sexual orientation (assuming they are heterosexual), sexual behaviors, and risk of unintended pregnancy and sexually transmitted diseases.
Youth reported that they are open to conversations about reproductive health and safe sex, but get turned off when providers incorrectly assume they are heterosexual and in need of birth control. Asking about sexual attraction and the gender of partners as a routine part of any adolescent sexual history can help providers avoid these mistakes.
• “Have a discussion versus telling people what to do. Tell me why you are checking things and what they mean.”
Youth reported that they were interested in being active participants in their health care visits. They stated that if labs are being checked, they want to know why and what the results mean. When medications are prescribed or lifestyle changes are recommended, they want to discuss why these changes are necessary and have some input as to how these changes happen.
• “I like to have my privacy respected. It can be uncomfortable talking about things with my parents in the room.”
Many youth reported privacy and one-on-one time with their providers being important. They reported being uncomfortable or embarrassed talking about certain topics in front of their parents and valued providers who respected their privacy.
Private time with patients is not meant to cut parents out of the visit; rather it is meant to be a time when patients can openly discuss concerns with their providers and begin to take ownership of their health and bodies.
Many of the suggestions above are helpful in the care of all youth, regardless of sexual orientation and gender identity. Most of the qualities youth were looking for in providers were related to communication and respect and are in keeping with current research and guidelines on creating youth friendly services. Following these suggestions, and continuing to find ways to include youth in our conversations to improve health care, are just a few ways we can make youth feel more comfortable in this setting and hopefully begin to achieve health equity for all youth.
Acknowledgments
I appreciate the youth at Kaleidoscope Youth Center for giving their time and continually helping me improve the care I provide to all patients and allowing me to share this information with others.
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.
How young is too young? The optimal age for transitioning for transgender and gender nonconforming youth
The clinical management of transgender and gender nonconforming youth is a growing area in pediatric endocrinology and adolescent medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? Are children and adolescents capable of making life-changing decisions? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.
What are the risks of delaying transition until adulthood?
Available studies report the incidence of mental health problems among transgender and gender nonconforming youth are higher than the incidence in cisgender youth.1 This is especially true if they are unable to live as the gender with which they identify. de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition.2 This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes them to longer periods of gender dysphoria and to harassment and discrimination. There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery was done when the patient was younger with smaller breasts.3 Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age, which would prevent the development of the undesired secondary sex characteristics.
Can gender dysphoria be diagnosed at an early age?
Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty.4,5 Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put them through unnecessary risks.
One potential treatment for some prepubertal children with gender dysphoria is social transition; for example, using the preferred name and pronouns, change of clothing and hairstyle, and so on. This is reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence. Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner Stage 2,6,7 and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm their gender identity. Finally, children who have gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood.3
What are the medical risks with pubertal suppression and cross-sex hormones?
One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa) – such as leuprolide – is reduced bone mineral density (BMD).7 Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD,8 whereas other studies showed no difference in BMD between those treated with GnRHa versus those who were not,9,10 especially after resumption of puberty.
What are the medical risks of using cross-sex hormones?
Likewise, use of cross-sex hormones – like estrogen and testosterone – is not risk free. The most likely risks with estrogen are venous thromboembolic events including pulmonary emboli, blood clots, gallstones, elevated liver enzymes, weight gain, and high cholesterol. Polycythemia, weight gain, acne, male pattern baldness, and sleep apnea are risks associated with testosterone use.7 Additionally, use of these hormones can induce infertility, and this is not always reversible.6 Furthermore, there are some studies in animal and human models that highlight the importance of sex hormones in organizing the brain during the critical period of adolescence.11 There is some concern that pubertal suppression or the use of cross-sex hormones for transition during this time may disrupt this process. However, one prospective study showed that adolescents who received pubertal suppression and cross-sex hormones had no psychopathology as adults and even had improved mental health outcomes.12 Nevertheless, this is only one study and further studies should confirm that pubertal suppression and sex reassignment are beneficial to the patient.
Can children and adolescents make complex, life-changing decisions?
The ethical issues of managing gender dysphoria in children and adolescents are the avoidance of harm – in both treatment and delaying treatment until the patient is older – and determining if children and adolescents are capable of making important decisions. Many would argue that children are not capable of making complex, life-changing decisions. For example, we wouldn’t expect an 8-year-old recently diagnosed with cancer to decide whether to proceed with treatment, knowing the potential side effects. Nevertheless, the recommended treatment for children is social transition. This process is reversible with little psychological and medical consequences.
However, adolescence can cloud the issue. Depending on the state, teenagers can obtain care for sexually transmitted infections (STIs) and contraception services without parental consent. Prevention of the spread of STIs and unwanted pregnancy are the primary rationales behind this, as adolescents are less likely to obtain these services if doing so required parental consent.13 However, underlying this rationale is the belief that adolescents are capable of making some complex decisions. Although the treatment of STIs or preventing unwanted pregnancy is not as complex as pubertal suppression or use of cross-sex hormones, the consequences of foregoing medical care of STIs (for example, the possibility of infertility due to pelvic inflammatory disease) or unexpected pregnancy are also life-changing.
One also must remember that not all adolescents reach their developmental milestones at the same age. A 14-year-old may have cognitive and executive functioning advanced for their age whereas an 18-year-old may lack these skills. Because of this variation, an interdisciplinary team including clinicians and behavioral/mental health experts should help individuals through the process of characterizing their self-identified gender identity and support their eventual transition using, as indicated for each individual, pubertal suppression, cross-sex hormones, and, ultimately, surgery.
The treatment of gender dysphoria in children and adolescents is characterized by ethical, medical, and psychosocial dilemmas. Long-term data are not available to determine the optimal age for transition for each individual. Despite the long-term risks, some children and adolescents are capable of making some important decisions. Furthermore, some treatment recommendations for children and adolescents who have gender dysphoria are reversible. At the end of the day, clinicians must combine the limited evidence with their experience to make the best judgment on how to proceed. Most important of all, they should allow the child to lead because he/she is the best judge of his/her gender identity.
References:
1. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011).
2. Psychiatry Res. 2011 Apr 30;186(2-3):414-8.
3. Nat Rev Endocrinol. 2011 May 17;7(8):466-72.
4. Dev Psychol. 2008 Jan;44(1):34-45.
5. J Adolesc Health. 2015 Oct;57(4):367-73.
6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
8. J Clin Endocrinol Metab. 2008 Jan;93(1):190-5.
9. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17.
10. Clinics (Sao Paulo). 2012;67(6):591-6.
11. Front Neuroendocrinol. 2005 Oct-Dec;26(3-4):163-74.
12. Pediatrics. 2014 Oct;134(4):696-704.
13. Arch Pediatr Adolesc Med. 2000;154(9):885-92.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.
The clinical management of transgender and gender nonconforming youth is a growing area in pediatric endocrinology and adolescent medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? Are children and adolescents capable of making life-changing decisions? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.
What are the risks of delaying transition until adulthood?
Available studies report the incidence of mental health problems among transgender and gender nonconforming youth are higher than the incidence in cisgender youth.1 This is especially true if they are unable to live as the gender with which they identify. de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition.2 This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes them to longer periods of gender dysphoria and to harassment and discrimination. There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery was done when the patient was younger with smaller breasts.3 Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age, which would prevent the development of the undesired secondary sex characteristics.
Can gender dysphoria be diagnosed at an early age?
Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty.4,5 Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put them through unnecessary risks.
One potential treatment for some prepubertal children with gender dysphoria is social transition; for example, using the preferred name and pronouns, change of clothing and hairstyle, and so on. This is reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence. Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner Stage 2,6,7 and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm their gender identity. Finally, children who have gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood.3
What are the medical risks with pubertal suppression and cross-sex hormones?
One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa) – such as leuprolide – is reduced bone mineral density (BMD).7 Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD,8 whereas other studies showed no difference in BMD between those treated with GnRHa versus those who were not,9,10 especially after resumption of puberty.
What are the medical risks of using cross-sex hormones?
Likewise, use of cross-sex hormones – like estrogen and testosterone – is not risk free. The most likely risks with estrogen are venous thromboembolic events including pulmonary emboli, blood clots, gallstones, elevated liver enzymes, weight gain, and high cholesterol. Polycythemia, weight gain, acne, male pattern baldness, and sleep apnea are risks associated with testosterone use.7 Additionally, use of these hormones can induce infertility, and this is not always reversible.6 Furthermore, there are some studies in animal and human models that highlight the importance of sex hormones in organizing the brain during the critical period of adolescence.11 There is some concern that pubertal suppression or the use of cross-sex hormones for transition during this time may disrupt this process. However, one prospective study showed that adolescents who received pubertal suppression and cross-sex hormones had no psychopathology as adults and even had improved mental health outcomes.12 Nevertheless, this is only one study and further studies should confirm that pubertal suppression and sex reassignment are beneficial to the patient.
Can children and adolescents make complex, life-changing decisions?
The ethical issues of managing gender dysphoria in children and adolescents are the avoidance of harm – in both treatment and delaying treatment until the patient is older – and determining if children and adolescents are capable of making important decisions. Many would argue that children are not capable of making complex, life-changing decisions. For example, we wouldn’t expect an 8-year-old recently diagnosed with cancer to decide whether to proceed with treatment, knowing the potential side effects. Nevertheless, the recommended treatment for children is social transition. This process is reversible with little psychological and medical consequences.
However, adolescence can cloud the issue. Depending on the state, teenagers can obtain care for sexually transmitted infections (STIs) and contraception services without parental consent. Prevention of the spread of STIs and unwanted pregnancy are the primary rationales behind this, as adolescents are less likely to obtain these services if doing so required parental consent.13 However, underlying this rationale is the belief that adolescents are capable of making some complex decisions. Although the treatment of STIs or preventing unwanted pregnancy is not as complex as pubertal suppression or use of cross-sex hormones, the consequences of foregoing medical care of STIs (for example, the possibility of infertility due to pelvic inflammatory disease) or unexpected pregnancy are also life-changing.
One also must remember that not all adolescents reach their developmental milestones at the same age. A 14-year-old may have cognitive and executive functioning advanced for their age whereas an 18-year-old may lack these skills. Because of this variation, an interdisciplinary team including clinicians and behavioral/mental health experts should help individuals through the process of characterizing their self-identified gender identity and support their eventual transition using, as indicated for each individual, pubertal suppression, cross-sex hormones, and, ultimately, surgery.
The treatment of gender dysphoria in children and adolescents is characterized by ethical, medical, and psychosocial dilemmas. Long-term data are not available to determine the optimal age for transition for each individual. Despite the long-term risks, some children and adolescents are capable of making some important decisions. Furthermore, some treatment recommendations for children and adolescents who have gender dysphoria are reversible. At the end of the day, clinicians must combine the limited evidence with their experience to make the best judgment on how to proceed. Most important of all, they should allow the child to lead because he/she is the best judge of his/her gender identity.
References:
1. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011).
2. Psychiatry Res. 2011 Apr 30;186(2-3):414-8.
3. Nat Rev Endocrinol. 2011 May 17;7(8):466-72.
4. Dev Psychol. 2008 Jan;44(1):34-45.
5. J Adolesc Health. 2015 Oct;57(4):367-73.
6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
8. J Clin Endocrinol Metab. 2008 Jan;93(1):190-5.
9. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17.
10. Clinics (Sao Paulo). 2012;67(6):591-6.
11. Front Neuroendocrinol. 2005 Oct-Dec;26(3-4):163-74.
12. Pediatrics. 2014 Oct;134(4):696-704.
13. Arch Pediatr Adolesc Med. 2000;154(9):885-92.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.
The clinical management of transgender and gender nonconforming youth is a growing area in pediatric endocrinology and adolescent medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? Are children and adolescents capable of making life-changing decisions? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.
What are the risks of delaying transition until adulthood?
Available studies report the incidence of mental health problems among transgender and gender nonconforming youth are higher than the incidence in cisgender youth.1 This is especially true if they are unable to live as the gender with which they identify. de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition.2 This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes them to longer periods of gender dysphoria and to harassment and discrimination. There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery was done when the patient was younger with smaller breasts.3 Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age, which would prevent the development of the undesired secondary sex characteristics.
Can gender dysphoria be diagnosed at an early age?
Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty.4,5 Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put them through unnecessary risks.
One potential treatment for some prepubertal children with gender dysphoria is social transition; for example, using the preferred name and pronouns, change of clothing and hairstyle, and so on. This is reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence. Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner Stage 2,6,7 and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm their gender identity. Finally, children who have gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood.3
What are the medical risks with pubertal suppression and cross-sex hormones?
One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa) – such as leuprolide – is reduced bone mineral density (BMD).7 Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD,8 whereas other studies showed no difference in BMD between those treated with GnRHa versus those who were not,9,10 especially after resumption of puberty.
What are the medical risks of using cross-sex hormones?
Likewise, use of cross-sex hormones – like estrogen and testosterone – is not risk free. The most likely risks with estrogen are venous thromboembolic events including pulmonary emboli, blood clots, gallstones, elevated liver enzymes, weight gain, and high cholesterol. Polycythemia, weight gain, acne, male pattern baldness, and sleep apnea are risks associated with testosterone use.7 Additionally, use of these hormones can induce infertility, and this is not always reversible.6 Furthermore, there are some studies in animal and human models that highlight the importance of sex hormones in organizing the brain during the critical period of adolescence.11 There is some concern that pubertal suppression or the use of cross-sex hormones for transition during this time may disrupt this process. However, one prospective study showed that adolescents who received pubertal suppression and cross-sex hormones had no psychopathology as adults and even had improved mental health outcomes.12 Nevertheless, this is only one study and further studies should confirm that pubertal suppression and sex reassignment are beneficial to the patient.
Can children and adolescents make complex, life-changing decisions?
The ethical issues of managing gender dysphoria in children and adolescents are the avoidance of harm – in both treatment and delaying treatment until the patient is older – and determining if children and adolescents are capable of making important decisions. Many would argue that children are not capable of making complex, life-changing decisions. For example, we wouldn’t expect an 8-year-old recently diagnosed with cancer to decide whether to proceed with treatment, knowing the potential side effects. Nevertheless, the recommended treatment for children is social transition. This process is reversible with little psychological and medical consequences.
However, adolescence can cloud the issue. Depending on the state, teenagers can obtain care for sexually transmitted infections (STIs) and contraception services without parental consent. Prevention of the spread of STIs and unwanted pregnancy are the primary rationales behind this, as adolescents are less likely to obtain these services if doing so required parental consent.13 However, underlying this rationale is the belief that adolescents are capable of making some complex decisions. Although the treatment of STIs or preventing unwanted pregnancy is not as complex as pubertal suppression or use of cross-sex hormones, the consequences of foregoing medical care of STIs (for example, the possibility of infertility due to pelvic inflammatory disease) or unexpected pregnancy are also life-changing.
One also must remember that not all adolescents reach their developmental milestones at the same age. A 14-year-old may have cognitive and executive functioning advanced for their age whereas an 18-year-old may lack these skills. Because of this variation, an interdisciplinary team including clinicians and behavioral/mental health experts should help individuals through the process of characterizing their self-identified gender identity and support their eventual transition using, as indicated for each individual, pubertal suppression, cross-sex hormones, and, ultimately, surgery.
The treatment of gender dysphoria in children and adolescents is characterized by ethical, medical, and psychosocial dilemmas. Long-term data are not available to determine the optimal age for transition for each individual. Despite the long-term risks, some children and adolescents are capable of making some important decisions. Furthermore, some treatment recommendations for children and adolescents who have gender dysphoria are reversible. At the end of the day, clinicians must combine the limited evidence with their experience to make the best judgment on how to proceed. Most important of all, they should allow the child to lead because he/she is the best judge of his/her gender identity.
References:
1. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011).
2. Psychiatry Res. 2011 Apr 30;186(2-3):414-8.
3. Nat Rev Endocrinol. 2011 May 17;7(8):466-72.
4. Dev Psychol. 2008 Jan;44(1):34-45.
5. J Adolesc Health. 2015 Oct;57(4):367-73.
6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
8. J Clin Endocrinol Metab. 2008 Jan;93(1):190-5.
9. J Clin Endocrinol Metab. 2010 Jan;95(1):109-17.
10. Clinics (Sao Paulo). 2012;67(6):591-6.
11. Front Neuroendocrinol. 2005 Oct-Dec;26(3-4):163-74.
12. Pediatrics. 2014 Oct;134(4):696-704.
13. Arch Pediatr Adolesc Med. 2000;154(9):885-92.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.
Why access to public bathrooms matters
Going to the movies is something I have always enjoyed. What I don’t always enjoy is waiting in line to use the bathroom after the movie is over and invariably picking a stall that has run out of toilet paper or that is in need of cleaning. These minor inconveniences in no way compare to the experiences some of my transgender patients have shared with me. Many of my patients tell me that they avoid using bathrooms in public places because of the anxiety they feel at having to pick a bathroom. Do they use the one that matches their sex assigned at birth or the one that matches their gender identity? Will they be safe and free from harassment in either bathroom? Some of my patients tell me they avoid drinking water at school just so they do not have to deal with going to the bathroom there.
Recently there have been bills introduced in several states that seek to deny transgender youth access to sex-segregated spaces including restrooms and locker rooms. These bills stigmatize an already vulnerable population, potentially increasing their risk of negative health outcomes. In a survey of transgender people in Massachusetts, 65% of respondents reported being discriminated against in public accommodations, and this discrimination was associated with poorer mental and physical health outcomes.1
In February of 2016, the American Academy of Pediatrics and several other organizations dedicated to the health and welfare of children came out with a letter to state governors in opposition to these bills.2 It states: “Transgender kids are already at heightened risk for violence, bullying, and harassment, and these bills exacerbate those risks by creating a hostile environment. … In addition, students who would be affected by these bills are among our most vulnerable to experiencing depression and engaging in self-harm, including suicide.”
On May 13, 2016, the U.S. Department of Justice and the U.S. Department of Education jointly issued a letter directing public schools to allow transgender students to use bathrooms that correspond with their gender identity.3 The letter was accompanied by a 25-page document with examples of policies and emerging practices to support transgender students.4
Proponents of these bills state that their purpose is to increase public safety and protect privacy. There are concerns that individuals may take advantage of these policies to sexually harass people in sex-segregated spaces. To date, there are no data to support these claims. In interviews conducted with heads of state police departments in 12 states that have nondiscrimination laws to protect transgender people in public settings, not one of the participants indicated any increase in sexual harassment or abuse in connection with these laws.1 In addition, should any type of harassment occur, it would not be protected under antidiscrimination laws, and perpetrators would be subject to criminal penalties.
What can we do as health care providers to support our patients?
• Educate ourselves. Keep up to date with best practice guidelines and evidence on how to promote the health and well-being of all children. The National LGBT Health Education Center has many educational resources to help health care providers provide quality care to LGBT patients and families. It is important to be aware of resources to help patients and families be aware of their rights and advocate for themselves in other settings such as school and work. Two organizations that provide this support and information are Trans Youth Family Allies and Lambda Legal.
• Create safe spaces. Create spaces in our practice settings where children and youth can safely explore their gender identity and gender expression. This can be done by providing access to gender-neutral bathrooms, prominently displaying nondiscrimination policies that are inclusive of gender identity, and modeling recognition of the variety of ways gender can be experienced by asking and using patients’ preferred names and pronouns.
• Advocate. Advocate for gender-inclusive environments within local youth-serving organizations including schools, medical facilities, and child welfare agencies. Share available information about the potential negative health effects of stigmatization and discrimination in transgender youth.
Together we can work to promote the well-being of all children.
Resources
• The National LGBT Health Education Center (www.lgbthealtheducation.org/).
• Trans Youth Family Allies (www.imatyfa.org/).
• Lambda Legal (www.lambdalegal.org/know-your-rights/youth).
References
1. Policy Brief: State Anti-transgender Bathroom Bills Threaten Transgender People’s Health and Participation in Public Life. Fenway Institute and Center for American Progress, 2016.
2. American Academy of Pediatrics letter on sex-segregated spaces (www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/AAP_HRCLetter.pdf).
3. Department of Justice and Department of Education Dear Colleague Letter on Transgender Students (www.justice.gov/opa/file/850996/download).
4. Department of Education Examples of Policies and Emerging Practices for Supporting Transgender Students (www2.ed.gov/about/offices/list/oese/oshs/emergingpractices.pdf).
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.
Going to the movies is something I have always enjoyed. What I don’t always enjoy is waiting in line to use the bathroom after the movie is over and invariably picking a stall that has run out of toilet paper or that is in need of cleaning. These minor inconveniences in no way compare to the experiences some of my transgender patients have shared with me. Many of my patients tell me that they avoid using bathrooms in public places because of the anxiety they feel at having to pick a bathroom. Do they use the one that matches their sex assigned at birth or the one that matches their gender identity? Will they be safe and free from harassment in either bathroom? Some of my patients tell me they avoid drinking water at school just so they do not have to deal with going to the bathroom there.
Recently there have been bills introduced in several states that seek to deny transgender youth access to sex-segregated spaces including restrooms and locker rooms. These bills stigmatize an already vulnerable population, potentially increasing their risk of negative health outcomes. In a survey of transgender people in Massachusetts, 65% of respondents reported being discriminated against in public accommodations, and this discrimination was associated with poorer mental and physical health outcomes.1
In February of 2016, the American Academy of Pediatrics and several other organizations dedicated to the health and welfare of children came out with a letter to state governors in opposition to these bills.2 It states: “Transgender kids are already at heightened risk for violence, bullying, and harassment, and these bills exacerbate those risks by creating a hostile environment. … In addition, students who would be affected by these bills are among our most vulnerable to experiencing depression and engaging in self-harm, including suicide.”
On May 13, 2016, the U.S. Department of Justice and the U.S. Department of Education jointly issued a letter directing public schools to allow transgender students to use bathrooms that correspond with their gender identity.3 The letter was accompanied by a 25-page document with examples of policies and emerging practices to support transgender students.4
Proponents of these bills state that their purpose is to increase public safety and protect privacy. There are concerns that individuals may take advantage of these policies to sexually harass people in sex-segregated spaces. To date, there are no data to support these claims. In interviews conducted with heads of state police departments in 12 states that have nondiscrimination laws to protect transgender people in public settings, not one of the participants indicated any increase in sexual harassment or abuse in connection with these laws.1 In addition, should any type of harassment occur, it would not be protected under antidiscrimination laws, and perpetrators would be subject to criminal penalties.
What can we do as health care providers to support our patients?
• Educate ourselves. Keep up to date with best practice guidelines and evidence on how to promote the health and well-being of all children. The National LGBT Health Education Center has many educational resources to help health care providers provide quality care to LGBT patients and families. It is important to be aware of resources to help patients and families be aware of their rights and advocate for themselves in other settings such as school and work. Two organizations that provide this support and information are Trans Youth Family Allies and Lambda Legal.
• Create safe spaces. Create spaces in our practice settings where children and youth can safely explore their gender identity and gender expression. This can be done by providing access to gender-neutral bathrooms, prominently displaying nondiscrimination policies that are inclusive of gender identity, and modeling recognition of the variety of ways gender can be experienced by asking and using patients’ preferred names and pronouns.
• Advocate. Advocate for gender-inclusive environments within local youth-serving organizations including schools, medical facilities, and child welfare agencies. Share available information about the potential negative health effects of stigmatization and discrimination in transgender youth.
Together we can work to promote the well-being of all children.
Resources
• The National LGBT Health Education Center (www.lgbthealtheducation.org/).
• Trans Youth Family Allies (www.imatyfa.org/).
• Lambda Legal (www.lambdalegal.org/know-your-rights/youth).
References
1. Policy Brief: State Anti-transgender Bathroom Bills Threaten Transgender People’s Health and Participation in Public Life. Fenway Institute and Center for American Progress, 2016.
2. American Academy of Pediatrics letter on sex-segregated spaces (www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/AAP_HRCLetter.pdf).
3. Department of Justice and Department of Education Dear Colleague Letter on Transgender Students (www.justice.gov/opa/file/850996/download).
4. Department of Education Examples of Policies and Emerging Practices for Supporting Transgender Students (www2.ed.gov/about/offices/list/oese/oshs/emergingpractices.pdf).
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.
Going to the movies is something I have always enjoyed. What I don’t always enjoy is waiting in line to use the bathroom after the movie is over and invariably picking a stall that has run out of toilet paper or that is in need of cleaning. These minor inconveniences in no way compare to the experiences some of my transgender patients have shared with me. Many of my patients tell me that they avoid using bathrooms in public places because of the anxiety they feel at having to pick a bathroom. Do they use the one that matches their sex assigned at birth or the one that matches their gender identity? Will they be safe and free from harassment in either bathroom? Some of my patients tell me they avoid drinking water at school just so they do not have to deal with going to the bathroom there.
Recently there have been bills introduced in several states that seek to deny transgender youth access to sex-segregated spaces including restrooms and locker rooms. These bills stigmatize an already vulnerable population, potentially increasing their risk of negative health outcomes. In a survey of transgender people in Massachusetts, 65% of respondents reported being discriminated against in public accommodations, and this discrimination was associated with poorer mental and physical health outcomes.1
In February of 2016, the American Academy of Pediatrics and several other organizations dedicated to the health and welfare of children came out with a letter to state governors in opposition to these bills.2 It states: “Transgender kids are already at heightened risk for violence, bullying, and harassment, and these bills exacerbate those risks by creating a hostile environment. … In addition, students who would be affected by these bills are among our most vulnerable to experiencing depression and engaging in self-harm, including suicide.”
On May 13, 2016, the U.S. Department of Justice and the U.S. Department of Education jointly issued a letter directing public schools to allow transgender students to use bathrooms that correspond with their gender identity.3 The letter was accompanied by a 25-page document with examples of policies and emerging practices to support transgender students.4
Proponents of these bills state that their purpose is to increase public safety and protect privacy. There are concerns that individuals may take advantage of these policies to sexually harass people in sex-segregated spaces. To date, there are no data to support these claims. In interviews conducted with heads of state police departments in 12 states that have nondiscrimination laws to protect transgender people in public settings, not one of the participants indicated any increase in sexual harassment or abuse in connection with these laws.1 In addition, should any type of harassment occur, it would not be protected under antidiscrimination laws, and perpetrators would be subject to criminal penalties.
What can we do as health care providers to support our patients?
• Educate ourselves. Keep up to date with best practice guidelines and evidence on how to promote the health and well-being of all children. The National LGBT Health Education Center has many educational resources to help health care providers provide quality care to LGBT patients and families. It is important to be aware of resources to help patients and families be aware of their rights and advocate for themselves in other settings such as school and work. Two organizations that provide this support and information are Trans Youth Family Allies and Lambda Legal.
• Create safe spaces. Create spaces in our practice settings where children and youth can safely explore their gender identity and gender expression. This can be done by providing access to gender-neutral bathrooms, prominently displaying nondiscrimination policies that are inclusive of gender identity, and modeling recognition of the variety of ways gender can be experienced by asking and using patients’ preferred names and pronouns.
• Advocate. Advocate for gender-inclusive environments within local youth-serving organizations including schools, medical facilities, and child welfare agencies. Share available information about the potential negative health effects of stigmatization and discrimination in transgender youth.
Together we can work to promote the well-being of all children.
Resources
• The National LGBT Health Education Center (www.lgbthealtheducation.org/).
• Trans Youth Family Allies (www.imatyfa.org/).
• Lambda Legal (www.lambdalegal.org/know-your-rights/youth).
References
1. Policy Brief: State Anti-transgender Bathroom Bills Threaten Transgender People’s Health and Participation in Public Life. Fenway Institute and Center for American Progress, 2016.
2. American Academy of Pediatrics letter on sex-segregated spaces (www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/AAP_HRCLetter.pdf).
3. Department of Justice and Department of Education Dear Colleague Letter on Transgender Students (www.justice.gov/opa/file/850996/download).
4. Department of Education Examples of Policies and Emerging Practices for Supporting Transgender Students (www2.ed.gov/about/offices/list/oese/oshs/emergingpractices.pdf).
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.
Bullying
A mentor told me during my pediatrics residency that going to school is “the main job of a teenager.” This is because at school, teenagers will be spending the majority of their time and energy learning and growing to become a thriving adult. However, the school environment matters. We are familiar with how excellent teachers, the availability of tutoring, and an administration dedicated to academic achievement play a big role. We also should be aware that if teenagers feel unsafe going to school – especially if they are victims of bullying – they are unable to take advantage of these resources.
Bullying is a repetitive, unwanted, and aggressive behavior among children and adolescents that involves a real or perceived power imbalance.1 Despite the increasing visibility of lesbian, gay, bisexual, and transgender (LGBT) individuals, bullying remains a serious problem for this population. Although between one in four and one in three of all youth experience bullying,2 according to the Youth Risk Behavior Survey, LGBT students are two to four times as likely to be threatened or injured with a weapon on school property, two to three times as likely not to go to school because they feel unsafe, and about two times as likely to be bullied at school, compared with their heterosexual peers.3 Alarmingly, more than half of transgender students experience bullying and harassment at school.4
A key component of bullying is the power imbalance. Bullying perpetrators feel that they have more power physically (e.g., in size) or socially (e.g., in social status).5 LGBT youth are often the victims of bullying because of the societal stigma against same-sex attraction or gender nonconformity. As a result, they tend to have a lower social status, putting them at risk for bullying. Remember, however, that this power imbalance is perceived. Even straight teenagers can be victims of antigay and antitrans bullying because they don’t conform to gender norms (e.g., a straight boy interested in theater instead of sports).6 Therefore, any teenager can be a victim of antigay and antitrans bullying.
Although many believe that experiencing bullying is a “rite of passage,” a look at the research on bullying contradicts this. Youth who experience bullying have higher rates of depression, loneliness, and, most worrisome of all, suicide.7,8 One study showed that LGBT youth who experience bullying are almost six times as likely to consider suicide.9 Such sobering statistics prove that bullying is harmful. Furthermore, the effects of bullying can last into adulthood. One study showed that LGBT youth who experienced bullying during high school are more likely to have depressive symptoms and to be dissatisfied with life as a young adult.10 If rites of passage are designed to make a teenager into a well-adjusted young adult, then bullying does a poor job.
Although antigay bullying and harassment occur outside the clinic, providers can encounter both the perpetrator and the victim as patients and not realize it. Providers who have patients at risk for bullying – such as LGBT or gender-nonconforming youth – should routinely ask them about bullying through such questions as:
• “How many good friends do you have in school?”
• “Do you ever feel afraid to go to school? Why?”
• “Do other kids ever bully you at school, in your neighborhood, or online? Who bullies you?
• When and where does it happen? What do they say or do?”11
Asking these questions is especially important if you or your patient’s caregivers notice school phobia, attention problems, or psychosomatic complaints.11 Once you identify a victim, refer the patient to a mental health provider to develop skills to cope with the stress of bullying. Such skills include how to make friends. Emphasize that it is not the victim’s fault that they are experiencing bullying. Avoid telling victims to fight back or “suck it up.” In addition, work with parents and school authorities to intervene on behalf of the child to stop the bullying behavior.
At the same time, it is especially important to identify perpetrators. Perpetrators tend to have conduct problems, increased depressive symptoms, and poor school adjustment.12 They may have been bullied themselves. Also refer perpetrators to a mental health provider and other resources to address these problems.
However, with your limited time to screen for bullying or to create an individualized plan to protect bullying victims, approaches to reducing bullying and their adverse effects require a community effort. Use your expertise and access to the latest scientific research to advocate and help create policies schools can use to address antigay bullying. Clark and Tilly recommend a three-tier approach in addressing antigay bullying. In the first tier, schools should create a safe and affirmative environment for all students. An example of such an approach is to have a speaker – such as a physician from the community – talking to students about bullying and encouraging bystanders to speak up (i.e., be an ally) for bullying victims. Although some schools may be hesitant to implement a schoolwide intervention, they may implement a second-tier approach, such as classroom curricula on how to be an ally or incentive programs for helping vulnerable students (e.g., tutoring). Finally, the third tier requires intensive individualized interventions for bullying victims. Schools should have a step-by-step plan involving school authorities that students and their parents can use if students are experiencing bullying.13 Implementation of this plan requires timely follow-up from school officials to ensure cessation of the bullying behavior.10
Another way you can advocate for your LGBT patients is to be knowledgeable about the laws surrounding bullying. Bullying laws vary according to state. This is especially true if such laws specifically prohibit bullying based on sexual orientation or gender identity. This is known as “enumeration.” Enumerated laws grant school authorities the power to prevent and to correct any bullying based on sexual orientation and gender identity. Currently, 18 states and the District of Columbia have enumerated antibullying laws.14 If you live in a state that does not have an enumerated antibullying law, you can contact your state government officials to urge them to pass such a law.
Bullying has a powerful impact on the health and well-being of LGBT youth. Screen for bullying in your LGBT patients and work with schools and parents to protect them from such behaviors. Most importantly, advocate for creating a safe school environment for LGBT youth so that they can focus on their main job of learning and becoming a thriving adult.
Resources
• The website www.stopbullying.gov is a comprehensive resource for bullying and how to address it.
• Society of Adolescent Health & Medicine (SAHM) position statement on bullying (J Adolesc Health. 2005 Jan;36[1]:88-91).
• American Academy of Pediatrics (AAP) position statement on bullying (Pediatrics. 2009 July. doi: 10.1542/peds.2009-0943).
• Gay, Lesbian & Straight Education Network (GLSEN) information on enumerated antibullying laws by state (www.glsen.org/article/state-maps).
References
1. Bullying definition at www.stopbullying.gov.
3. J Adolesc Health. 2014 Sep;55(3):432-8.
5. Can Fam Physician. 2009 Apr;55(4):356-60.
6. J Adolesc Health. 2016 Feb;58(2):S1-S2.
7. Pediatrics. 2003;111(6 Pt 1):1312-7.
8. Journal of Educational Psychology. 2000 Jun;92(2):349-59.
9. Prev Sci. 2015 Apr;16(3):451-62.
10. Dev Psychol. 2010 Nov;46(6):1580-9.
11. Roles for pediatricians in bullying prevention and intervention (www.stopbullying.gov/resources-files/roles-for-pediatricians-tipsheet.pdf).
12. J Adolesc Health. 2005 Jan;36(1):88-91.
13. Clark JP, Tilly, WD. The evolution of response to intervention. In: Clark JP, Alvarez, Michelle, ed. Response to intervention: A guide for school social worker. (New York: Oxford University Press; 2010:3-18).
14. Enumerated antibullying laws by state(www.glsen.org/article/state-maps).
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh.
A mentor told me during my pediatrics residency that going to school is “the main job of a teenager.” This is because at school, teenagers will be spending the majority of their time and energy learning and growing to become a thriving adult. However, the school environment matters. We are familiar with how excellent teachers, the availability of tutoring, and an administration dedicated to academic achievement play a big role. We also should be aware that if teenagers feel unsafe going to school – especially if they are victims of bullying – they are unable to take advantage of these resources.
Bullying is a repetitive, unwanted, and aggressive behavior among children and adolescents that involves a real or perceived power imbalance.1 Despite the increasing visibility of lesbian, gay, bisexual, and transgender (LGBT) individuals, bullying remains a serious problem for this population. Although between one in four and one in three of all youth experience bullying,2 according to the Youth Risk Behavior Survey, LGBT students are two to four times as likely to be threatened or injured with a weapon on school property, two to three times as likely not to go to school because they feel unsafe, and about two times as likely to be bullied at school, compared with their heterosexual peers.3 Alarmingly, more than half of transgender students experience bullying and harassment at school.4
A key component of bullying is the power imbalance. Bullying perpetrators feel that they have more power physically (e.g., in size) or socially (e.g., in social status).5 LGBT youth are often the victims of bullying because of the societal stigma against same-sex attraction or gender nonconformity. As a result, they tend to have a lower social status, putting them at risk for bullying. Remember, however, that this power imbalance is perceived. Even straight teenagers can be victims of antigay and antitrans bullying because they don’t conform to gender norms (e.g., a straight boy interested in theater instead of sports).6 Therefore, any teenager can be a victim of antigay and antitrans bullying.
Although many believe that experiencing bullying is a “rite of passage,” a look at the research on bullying contradicts this. Youth who experience bullying have higher rates of depression, loneliness, and, most worrisome of all, suicide.7,8 One study showed that LGBT youth who experience bullying are almost six times as likely to consider suicide.9 Such sobering statistics prove that bullying is harmful. Furthermore, the effects of bullying can last into adulthood. One study showed that LGBT youth who experienced bullying during high school are more likely to have depressive symptoms and to be dissatisfied with life as a young adult.10 If rites of passage are designed to make a teenager into a well-adjusted young adult, then bullying does a poor job.
Although antigay bullying and harassment occur outside the clinic, providers can encounter both the perpetrator and the victim as patients and not realize it. Providers who have patients at risk for bullying – such as LGBT or gender-nonconforming youth – should routinely ask them about bullying through such questions as:
• “How many good friends do you have in school?”
• “Do you ever feel afraid to go to school? Why?”
• “Do other kids ever bully you at school, in your neighborhood, or online? Who bullies you?
• When and where does it happen? What do they say or do?”11
Asking these questions is especially important if you or your patient’s caregivers notice school phobia, attention problems, or psychosomatic complaints.11 Once you identify a victim, refer the patient to a mental health provider to develop skills to cope with the stress of bullying. Such skills include how to make friends. Emphasize that it is not the victim’s fault that they are experiencing bullying. Avoid telling victims to fight back or “suck it up.” In addition, work with parents and school authorities to intervene on behalf of the child to stop the bullying behavior.
At the same time, it is especially important to identify perpetrators. Perpetrators tend to have conduct problems, increased depressive symptoms, and poor school adjustment.12 They may have been bullied themselves. Also refer perpetrators to a mental health provider and other resources to address these problems.
However, with your limited time to screen for bullying or to create an individualized plan to protect bullying victims, approaches to reducing bullying and their adverse effects require a community effort. Use your expertise and access to the latest scientific research to advocate and help create policies schools can use to address antigay bullying. Clark and Tilly recommend a three-tier approach in addressing antigay bullying. In the first tier, schools should create a safe and affirmative environment for all students. An example of such an approach is to have a speaker – such as a physician from the community – talking to students about bullying and encouraging bystanders to speak up (i.e., be an ally) for bullying victims. Although some schools may be hesitant to implement a schoolwide intervention, they may implement a second-tier approach, such as classroom curricula on how to be an ally or incentive programs for helping vulnerable students (e.g., tutoring). Finally, the third tier requires intensive individualized interventions for bullying victims. Schools should have a step-by-step plan involving school authorities that students and their parents can use if students are experiencing bullying.13 Implementation of this plan requires timely follow-up from school officials to ensure cessation of the bullying behavior.10
Another way you can advocate for your LGBT patients is to be knowledgeable about the laws surrounding bullying. Bullying laws vary according to state. This is especially true if such laws specifically prohibit bullying based on sexual orientation or gender identity. This is known as “enumeration.” Enumerated laws grant school authorities the power to prevent and to correct any bullying based on sexual orientation and gender identity. Currently, 18 states and the District of Columbia have enumerated antibullying laws.14 If you live in a state that does not have an enumerated antibullying law, you can contact your state government officials to urge them to pass such a law.
Bullying has a powerful impact on the health and well-being of LGBT youth. Screen for bullying in your LGBT patients and work with schools and parents to protect them from such behaviors. Most importantly, advocate for creating a safe school environment for LGBT youth so that they can focus on their main job of learning and becoming a thriving adult.
Resources
• The website www.stopbullying.gov is a comprehensive resource for bullying and how to address it.
• Society of Adolescent Health & Medicine (SAHM) position statement on bullying (J Adolesc Health. 2005 Jan;36[1]:88-91).
• American Academy of Pediatrics (AAP) position statement on bullying (Pediatrics. 2009 July. doi: 10.1542/peds.2009-0943).
• Gay, Lesbian & Straight Education Network (GLSEN) information on enumerated antibullying laws by state (www.glsen.org/article/state-maps).
References
1. Bullying definition at www.stopbullying.gov.
3. J Adolesc Health. 2014 Sep;55(3):432-8.
5. Can Fam Physician. 2009 Apr;55(4):356-60.
6. J Adolesc Health. 2016 Feb;58(2):S1-S2.
7. Pediatrics. 2003;111(6 Pt 1):1312-7.
8. Journal of Educational Psychology. 2000 Jun;92(2):349-59.
9. Prev Sci. 2015 Apr;16(3):451-62.
10. Dev Psychol. 2010 Nov;46(6):1580-9.
11. Roles for pediatricians in bullying prevention and intervention (www.stopbullying.gov/resources-files/roles-for-pediatricians-tipsheet.pdf).
12. J Adolesc Health. 2005 Jan;36(1):88-91.
13. Clark JP, Tilly, WD. The evolution of response to intervention. In: Clark JP, Alvarez, Michelle, ed. Response to intervention: A guide for school social worker. (New York: Oxford University Press; 2010:3-18).
14. Enumerated antibullying laws by state(www.glsen.org/article/state-maps).
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh.
A mentor told me during my pediatrics residency that going to school is “the main job of a teenager.” This is because at school, teenagers will be spending the majority of their time and energy learning and growing to become a thriving adult. However, the school environment matters. We are familiar with how excellent teachers, the availability of tutoring, and an administration dedicated to academic achievement play a big role. We also should be aware that if teenagers feel unsafe going to school – especially if they are victims of bullying – they are unable to take advantage of these resources.
Bullying is a repetitive, unwanted, and aggressive behavior among children and adolescents that involves a real or perceived power imbalance.1 Despite the increasing visibility of lesbian, gay, bisexual, and transgender (LGBT) individuals, bullying remains a serious problem for this population. Although between one in four and one in three of all youth experience bullying,2 according to the Youth Risk Behavior Survey, LGBT students are two to four times as likely to be threatened or injured with a weapon on school property, two to three times as likely not to go to school because they feel unsafe, and about two times as likely to be bullied at school, compared with their heterosexual peers.3 Alarmingly, more than half of transgender students experience bullying and harassment at school.4
A key component of bullying is the power imbalance. Bullying perpetrators feel that they have more power physically (e.g., in size) or socially (e.g., in social status).5 LGBT youth are often the victims of bullying because of the societal stigma against same-sex attraction or gender nonconformity. As a result, they tend to have a lower social status, putting them at risk for bullying. Remember, however, that this power imbalance is perceived. Even straight teenagers can be victims of antigay and antitrans bullying because they don’t conform to gender norms (e.g., a straight boy interested in theater instead of sports).6 Therefore, any teenager can be a victim of antigay and antitrans bullying.
Although many believe that experiencing bullying is a “rite of passage,” a look at the research on bullying contradicts this. Youth who experience bullying have higher rates of depression, loneliness, and, most worrisome of all, suicide.7,8 One study showed that LGBT youth who experience bullying are almost six times as likely to consider suicide.9 Such sobering statistics prove that bullying is harmful. Furthermore, the effects of bullying can last into adulthood. One study showed that LGBT youth who experienced bullying during high school are more likely to have depressive symptoms and to be dissatisfied with life as a young adult.10 If rites of passage are designed to make a teenager into a well-adjusted young adult, then bullying does a poor job.
Although antigay bullying and harassment occur outside the clinic, providers can encounter both the perpetrator and the victim as patients and not realize it. Providers who have patients at risk for bullying – such as LGBT or gender-nonconforming youth – should routinely ask them about bullying through such questions as:
• “How many good friends do you have in school?”
• “Do you ever feel afraid to go to school? Why?”
• “Do other kids ever bully you at school, in your neighborhood, or online? Who bullies you?
• When and where does it happen? What do they say or do?”11
Asking these questions is especially important if you or your patient’s caregivers notice school phobia, attention problems, or psychosomatic complaints.11 Once you identify a victim, refer the patient to a mental health provider to develop skills to cope with the stress of bullying. Such skills include how to make friends. Emphasize that it is not the victim’s fault that they are experiencing bullying. Avoid telling victims to fight back or “suck it up.” In addition, work with parents and school authorities to intervene on behalf of the child to stop the bullying behavior.
At the same time, it is especially important to identify perpetrators. Perpetrators tend to have conduct problems, increased depressive symptoms, and poor school adjustment.12 They may have been bullied themselves. Also refer perpetrators to a mental health provider and other resources to address these problems.
However, with your limited time to screen for bullying or to create an individualized plan to protect bullying victims, approaches to reducing bullying and their adverse effects require a community effort. Use your expertise and access to the latest scientific research to advocate and help create policies schools can use to address antigay bullying. Clark and Tilly recommend a three-tier approach in addressing antigay bullying. In the first tier, schools should create a safe and affirmative environment for all students. An example of such an approach is to have a speaker – such as a physician from the community – talking to students about bullying and encouraging bystanders to speak up (i.e., be an ally) for bullying victims. Although some schools may be hesitant to implement a schoolwide intervention, they may implement a second-tier approach, such as classroom curricula on how to be an ally or incentive programs for helping vulnerable students (e.g., tutoring). Finally, the third tier requires intensive individualized interventions for bullying victims. Schools should have a step-by-step plan involving school authorities that students and their parents can use if students are experiencing bullying.13 Implementation of this plan requires timely follow-up from school officials to ensure cessation of the bullying behavior.10
Another way you can advocate for your LGBT patients is to be knowledgeable about the laws surrounding bullying. Bullying laws vary according to state. This is especially true if such laws specifically prohibit bullying based on sexual orientation or gender identity. This is known as “enumeration.” Enumerated laws grant school authorities the power to prevent and to correct any bullying based on sexual orientation and gender identity. Currently, 18 states and the District of Columbia have enumerated antibullying laws.14 If you live in a state that does not have an enumerated antibullying law, you can contact your state government officials to urge them to pass such a law.
Bullying has a powerful impact on the health and well-being of LGBT youth. Screen for bullying in your LGBT patients and work with schools and parents to protect them from such behaviors. Most importantly, advocate for creating a safe school environment for LGBT youth so that they can focus on their main job of learning and becoming a thriving adult.
Resources
• The website www.stopbullying.gov is a comprehensive resource for bullying and how to address it.
• Society of Adolescent Health & Medicine (SAHM) position statement on bullying (J Adolesc Health. 2005 Jan;36[1]:88-91).
• American Academy of Pediatrics (AAP) position statement on bullying (Pediatrics. 2009 July. doi: 10.1542/peds.2009-0943).
• Gay, Lesbian & Straight Education Network (GLSEN) information on enumerated antibullying laws by state (www.glsen.org/article/state-maps).
References
1. Bullying definition at www.stopbullying.gov.
3. J Adolesc Health. 2014 Sep;55(3):432-8.
5. Can Fam Physician. 2009 Apr;55(4):356-60.
6. J Adolesc Health. 2016 Feb;58(2):S1-S2.
7. Pediatrics. 2003;111(6 Pt 1):1312-7.
8. Journal of Educational Psychology. 2000 Jun;92(2):349-59.
9. Prev Sci. 2015 Apr;16(3):451-62.
10. Dev Psychol. 2010 Nov;46(6):1580-9.
11. Roles for pediatricians in bullying prevention and intervention (www.stopbullying.gov/resources-files/roles-for-pediatricians-tipsheet.pdf).
12. J Adolesc Health. 2005 Jan;36(1):88-91.
13. Clark JP, Tilly, WD. The evolution of response to intervention. In: Clark JP, Alvarez, Michelle, ed. Response to intervention: A guide for school social worker. (New York: Oxford University Press; 2010:3-18).
14. Enumerated antibullying laws by state(www.glsen.org/article/state-maps).
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh.
Creating safe spaces for LGBTQ youth, families in health care settings
Ryan is a 15-year-old transmale patient (natal sex female who identifies as male and prefers male pronouns, he/him/his) who presents to the emergency department (ED) with suicidal thoughts that have increased with his period this month. His father explains to the registration staff that Ryan is transgender and while his legal name is still Rachel, he prefers to be addressed as Ryan and uses male pronouns. The registration person passes this on to the nurse who will be caring for Ryan. While in the ED, Ryan is frequently referred to by his birth name, Rachel, and female pronouns by various staff members. Dad corrects them, and staff are responsive to his feedback, but the continued misgendering increases Ryan’s suicidality to the point that dad considers leaving the ED.
Nakeia is a 2-month-old infant female brought to the clinic by her parents Shayla and Marie, who are a married lesbian couple. When the doctor walks in, she introduces herself to Shayla and when she sees Marie, she says, “It’s so nice that your mother came with you to the appointment today.” Marie is taken aback and wonders if they should search for another pediatrician who has experience working with LGB couples.
The two cases above are fictional cases created from a collection of experiences shared by patients and families that have presented to our clinics. While unintentional, the assumptions of staff and providers resulted in distress for the patient and families being cared for. What could have been done differently?
Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are less likely to access health care than are their non-LGBTQ peers for a variety of reasons. Perceived discrimination within the health care system, and health care providers’ lack of awareness and knowledge of LGBTQ specific health issues are factors that lead to decreased use of health care services.1 In a 2009 survey of LGBT adults, 56% of LGB respondents and 70% of transgender and gender nonconforming respondents reported experiencing at least one incident of discrimination in the health care setting.2 The Institute of Medicine (IOM), the Association of American Medical Colleges (AAMC), and the Joint Commission recommend specific training of health care providers on issues of LGBTQ health as one way of addressing these barriers.2,3,4 Despite these recommendations, many providers report that they are not adequately trained to provide care for LGBT patients.1
A number of resources are available to help health care providers and staff increase their competency in caring for LGBTQ patients and families. The National LGBT Health Education Center is one easy-to-use resource that has information on disparities in the LGBT community and strategies that can be implemented in practice to address these disparities. These strategies are not expensive to implement, but do require time, effort, and dedication from staff and providers to provide best quality care to all patients. Below are a few suggestions to create an inclusive health care environment adapted from the center’s guide on creating inclusive health care environments for LGBT people5:
All staff receive training on culturally affirming care for LGBT people.
• Training on terminology, health disparities, and how to avoid assumptions and stereotypes is important for all staff members. A positive or negative encounter with one staff member can set the tone for the whole visit.
• Respectful, nonjudgmental communication can help patients and families feel safe and comfortable and increases the likelihood that they remain engaged in care.
Processes and forms reflect the diversity of LGBT people and their relationships.
• Preferred names/pronouns. Many transgender patients have insurance cards and legal documents that do not reflect their current identity. Having a process where preferred names and pronouns can be recorded in the chart and easily communicated to other staff members is important. It is equally important that staff members are trained to recognize and use this information.
• Relationship questions. All staff members should ask the relationship of people accompanying patients to visits and not assume relationships.
• Sexual history questions. When asking or collecting information about sexual history, do not assume heterosexuality.
All patients receive routine sexual health histories.
• A confidential sexual health history should be part of the comprehensive history for all adolescent patients.
• Discussions should be broad, not only focusing on sexual behaviors and risks, but also addressing attraction, readiness for sex, health of relationships, sexual satisfaction, and history of trauma or abuse.
• Ask open-ended and inclusive questions, such as “Are you in a relationship?” “Are you attracted to men, women, both, neither?”
• Ask patients and parents if they have any concerns about gender identity. This offers an opportunity for patients and parents to discuss these issues.
• Avoid assumptions by asking these questions of all patients.
Clinical care and services incorporate LGBT health care needs.
LGBTQ youth in general have the same health and wellness needs as those of all patients. There are, however, health disparities that exist in this community related to stigma and minority stress. Clinicians should be aware of these disparities so they can provide targeted, individualized care.
• Gay men, bisexual men, and transgender women face higher rates of HIV and STIs. Culturally responsive prevention and testing is important, including availability of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) therapy for HIV as appropriate.
• Smoking and substance use rates are higher in LGBTQ youth; assessing for this and providing appropriate support is important.
• LGBTQ youth are at higher risk of depression, anxiety, suicidality, and bullying. Assessing for family and social support is important as these can be protective. Connecting parents and youth to support groups can be helpful.
• Transgender youth may require specialized services including counseling, psychiatric services, pubertal suppression, and cross-sex hormone therapy. Knowledge of where patients can be appropriately referred is important.
The physical environment welcomes and includes LGBT people.
Studies have shown that many LGBTQ youth and parents look for signs or clues that a clinic or facility is welcoming or safe. Below are some easy ways to communicate openness through the physical space.
• Signs and brochures. Prominently display clinic or institutional nondiscrimination policies. LGBT-friendly symbols such as the rainbow flag or safe zone signs can be displayed on placards, bulletin boards, or staff badges.
• Reading materials. Brochures, magazines and décor that contain images of couples and families should include same-sex couples and LGBT families. Reading materials should include topics relevant to the LGBTQ patients. Information about local LGBTQ resources should be available.
• Restrooms. Transgender and gender nonconforming youth often experience anxiety using public restrooms in part due to fear of harassment. Health care spaces should have policies that allow patients to use restrooms based on their gender identity rather than birth sex. If possible, it is helpful to provide access to single occupancy unisex restrooms.
Creating a space that is safe, welcoming, and respectful of LGBTQ patients and families is one way to begin addressing the health disparities that exist in this community. Below are resources to help your clinic or institution become one of these spaces.
1. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (National Academies Press: Washington, 2011).
2. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV (New York: Lambda Legal, 2010).
3. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Non-Conforming, or born with DSD: A Resource for Medical Educators. (AAMC: Washington, 2014).
4. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. (The Joint Commission: Oak Brook, Ill. 2011)
5. Ten Things: Creating Inclusive Health Care Environments for LGBT People. National LGBT Health Education Center (www.lgbthealtheducation.org).
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.
Ryan is a 15-year-old transmale patient (natal sex female who identifies as male and prefers male pronouns, he/him/his) who presents to the emergency department (ED) with suicidal thoughts that have increased with his period this month. His father explains to the registration staff that Ryan is transgender and while his legal name is still Rachel, he prefers to be addressed as Ryan and uses male pronouns. The registration person passes this on to the nurse who will be caring for Ryan. While in the ED, Ryan is frequently referred to by his birth name, Rachel, and female pronouns by various staff members. Dad corrects them, and staff are responsive to his feedback, but the continued misgendering increases Ryan’s suicidality to the point that dad considers leaving the ED.
Nakeia is a 2-month-old infant female brought to the clinic by her parents Shayla and Marie, who are a married lesbian couple. When the doctor walks in, she introduces herself to Shayla and when she sees Marie, she says, “It’s so nice that your mother came with you to the appointment today.” Marie is taken aback and wonders if they should search for another pediatrician who has experience working with LGB couples.
The two cases above are fictional cases created from a collection of experiences shared by patients and families that have presented to our clinics. While unintentional, the assumptions of staff and providers resulted in distress for the patient and families being cared for. What could have been done differently?
Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are less likely to access health care than are their non-LGBTQ peers for a variety of reasons. Perceived discrimination within the health care system, and health care providers’ lack of awareness and knowledge of LGBTQ specific health issues are factors that lead to decreased use of health care services.1 In a 2009 survey of LGBT adults, 56% of LGB respondents and 70% of transgender and gender nonconforming respondents reported experiencing at least one incident of discrimination in the health care setting.2 The Institute of Medicine (IOM), the Association of American Medical Colleges (AAMC), and the Joint Commission recommend specific training of health care providers on issues of LGBTQ health as one way of addressing these barriers.2,3,4 Despite these recommendations, many providers report that they are not adequately trained to provide care for LGBT patients.1
A number of resources are available to help health care providers and staff increase their competency in caring for LGBTQ patients and families. The National LGBT Health Education Center is one easy-to-use resource that has information on disparities in the LGBT community and strategies that can be implemented in practice to address these disparities. These strategies are not expensive to implement, but do require time, effort, and dedication from staff and providers to provide best quality care to all patients. Below are a few suggestions to create an inclusive health care environment adapted from the center’s guide on creating inclusive health care environments for LGBT people5:
All staff receive training on culturally affirming care for LGBT people.
• Training on terminology, health disparities, and how to avoid assumptions and stereotypes is important for all staff members. A positive or negative encounter with one staff member can set the tone for the whole visit.
• Respectful, nonjudgmental communication can help patients and families feel safe and comfortable and increases the likelihood that they remain engaged in care.
Processes and forms reflect the diversity of LGBT people and their relationships.
• Preferred names/pronouns. Many transgender patients have insurance cards and legal documents that do not reflect their current identity. Having a process where preferred names and pronouns can be recorded in the chart and easily communicated to other staff members is important. It is equally important that staff members are trained to recognize and use this information.
• Relationship questions. All staff members should ask the relationship of people accompanying patients to visits and not assume relationships.
• Sexual history questions. When asking or collecting information about sexual history, do not assume heterosexuality.
All patients receive routine sexual health histories.
• A confidential sexual health history should be part of the comprehensive history for all adolescent patients.
• Discussions should be broad, not only focusing on sexual behaviors and risks, but also addressing attraction, readiness for sex, health of relationships, sexual satisfaction, and history of trauma or abuse.
• Ask open-ended and inclusive questions, such as “Are you in a relationship?” “Are you attracted to men, women, both, neither?”
• Ask patients and parents if they have any concerns about gender identity. This offers an opportunity for patients and parents to discuss these issues.
• Avoid assumptions by asking these questions of all patients.
Clinical care and services incorporate LGBT health care needs.
LGBTQ youth in general have the same health and wellness needs as those of all patients. There are, however, health disparities that exist in this community related to stigma and minority stress. Clinicians should be aware of these disparities so they can provide targeted, individualized care.
• Gay men, bisexual men, and transgender women face higher rates of HIV and STIs. Culturally responsive prevention and testing is important, including availability of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) therapy for HIV as appropriate.
• Smoking and substance use rates are higher in LGBTQ youth; assessing for this and providing appropriate support is important.
• LGBTQ youth are at higher risk of depression, anxiety, suicidality, and bullying. Assessing for family and social support is important as these can be protective. Connecting parents and youth to support groups can be helpful.
• Transgender youth may require specialized services including counseling, psychiatric services, pubertal suppression, and cross-sex hormone therapy. Knowledge of where patients can be appropriately referred is important.
The physical environment welcomes and includes LGBT people.
Studies have shown that many LGBTQ youth and parents look for signs or clues that a clinic or facility is welcoming or safe. Below are some easy ways to communicate openness through the physical space.
• Signs and brochures. Prominently display clinic or institutional nondiscrimination policies. LGBT-friendly symbols such as the rainbow flag or safe zone signs can be displayed on placards, bulletin boards, or staff badges.
• Reading materials. Brochures, magazines and décor that contain images of couples and families should include same-sex couples and LGBT families. Reading materials should include topics relevant to the LGBTQ patients. Information about local LGBTQ resources should be available.
• Restrooms. Transgender and gender nonconforming youth often experience anxiety using public restrooms in part due to fear of harassment. Health care spaces should have policies that allow patients to use restrooms based on their gender identity rather than birth sex. If possible, it is helpful to provide access to single occupancy unisex restrooms.
Creating a space that is safe, welcoming, and respectful of LGBTQ patients and families is one way to begin addressing the health disparities that exist in this community. Below are resources to help your clinic or institution become one of these spaces.
1. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (National Academies Press: Washington, 2011).
2. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV (New York: Lambda Legal, 2010).
3. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Non-Conforming, or born with DSD: A Resource for Medical Educators. (AAMC: Washington, 2014).
4. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. (The Joint Commission: Oak Brook, Ill. 2011)
5. Ten Things: Creating Inclusive Health Care Environments for LGBT People. National LGBT Health Education Center (www.lgbthealtheducation.org).
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.
Ryan is a 15-year-old transmale patient (natal sex female who identifies as male and prefers male pronouns, he/him/his) who presents to the emergency department (ED) with suicidal thoughts that have increased with his period this month. His father explains to the registration staff that Ryan is transgender and while his legal name is still Rachel, he prefers to be addressed as Ryan and uses male pronouns. The registration person passes this on to the nurse who will be caring for Ryan. While in the ED, Ryan is frequently referred to by his birth name, Rachel, and female pronouns by various staff members. Dad corrects them, and staff are responsive to his feedback, but the continued misgendering increases Ryan’s suicidality to the point that dad considers leaving the ED.
Nakeia is a 2-month-old infant female brought to the clinic by her parents Shayla and Marie, who are a married lesbian couple. When the doctor walks in, she introduces herself to Shayla and when she sees Marie, she says, “It’s so nice that your mother came with you to the appointment today.” Marie is taken aback and wonders if they should search for another pediatrician who has experience working with LGB couples.
The two cases above are fictional cases created from a collection of experiences shared by patients and families that have presented to our clinics. While unintentional, the assumptions of staff and providers resulted in distress for the patient and families being cared for. What could have been done differently?
Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are less likely to access health care than are their non-LGBTQ peers for a variety of reasons. Perceived discrimination within the health care system, and health care providers’ lack of awareness and knowledge of LGBTQ specific health issues are factors that lead to decreased use of health care services.1 In a 2009 survey of LGBT adults, 56% of LGB respondents and 70% of transgender and gender nonconforming respondents reported experiencing at least one incident of discrimination in the health care setting.2 The Institute of Medicine (IOM), the Association of American Medical Colleges (AAMC), and the Joint Commission recommend specific training of health care providers on issues of LGBTQ health as one way of addressing these barriers.2,3,4 Despite these recommendations, many providers report that they are not adequately trained to provide care for LGBT patients.1
A number of resources are available to help health care providers and staff increase their competency in caring for LGBTQ patients and families. The National LGBT Health Education Center is one easy-to-use resource that has information on disparities in the LGBT community and strategies that can be implemented in practice to address these disparities. These strategies are not expensive to implement, but do require time, effort, and dedication from staff and providers to provide best quality care to all patients. Below are a few suggestions to create an inclusive health care environment adapted from the center’s guide on creating inclusive health care environments for LGBT people5:
All staff receive training on culturally affirming care for LGBT people.
• Training on terminology, health disparities, and how to avoid assumptions and stereotypes is important for all staff members. A positive or negative encounter with one staff member can set the tone for the whole visit.
• Respectful, nonjudgmental communication can help patients and families feel safe and comfortable and increases the likelihood that they remain engaged in care.
Processes and forms reflect the diversity of LGBT people and their relationships.
• Preferred names/pronouns. Many transgender patients have insurance cards and legal documents that do not reflect their current identity. Having a process where preferred names and pronouns can be recorded in the chart and easily communicated to other staff members is important. It is equally important that staff members are trained to recognize and use this information.
• Relationship questions. All staff members should ask the relationship of people accompanying patients to visits and not assume relationships.
• Sexual history questions. When asking or collecting information about sexual history, do not assume heterosexuality.
All patients receive routine sexual health histories.
• A confidential sexual health history should be part of the comprehensive history for all adolescent patients.
• Discussions should be broad, not only focusing on sexual behaviors and risks, but also addressing attraction, readiness for sex, health of relationships, sexual satisfaction, and history of trauma or abuse.
• Ask open-ended and inclusive questions, such as “Are you in a relationship?” “Are you attracted to men, women, both, neither?”
• Ask patients and parents if they have any concerns about gender identity. This offers an opportunity for patients and parents to discuss these issues.
• Avoid assumptions by asking these questions of all patients.
Clinical care and services incorporate LGBT health care needs.
LGBTQ youth in general have the same health and wellness needs as those of all patients. There are, however, health disparities that exist in this community related to stigma and minority stress. Clinicians should be aware of these disparities so they can provide targeted, individualized care.
• Gay men, bisexual men, and transgender women face higher rates of HIV and STIs. Culturally responsive prevention and testing is important, including availability of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) therapy for HIV as appropriate.
• Smoking and substance use rates are higher in LGBTQ youth; assessing for this and providing appropriate support is important.
• LGBTQ youth are at higher risk of depression, anxiety, suicidality, and bullying. Assessing for family and social support is important as these can be protective. Connecting parents and youth to support groups can be helpful.
• Transgender youth may require specialized services including counseling, psychiatric services, pubertal suppression, and cross-sex hormone therapy. Knowledge of where patients can be appropriately referred is important.
The physical environment welcomes and includes LGBT people.
Studies have shown that many LGBTQ youth and parents look for signs or clues that a clinic or facility is welcoming or safe. Below are some easy ways to communicate openness through the physical space.
• Signs and brochures. Prominently display clinic or institutional nondiscrimination policies. LGBT-friendly symbols such as the rainbow flag or safe zone signs can be displayed on placards, bulletin boards, or staff badges.
• Reading materials. Brochures, magazines and décor that contain images of couples and families should include same-sex couples and LGBT families. Reading materials should include topics relevant to the LGBTQ patients. Information about local LGBTQ resources should be available.
• Restrooms. Transgender and gender nonconforming youth often experience anxiety using public restrooms in part due to fear of harassment. Health care spaces should have policies that allow patients to use restrooms based on their gender identity rather than birth sex. If possible, it is helpful to provide access to single occupancy unisex restrooms.
Creating a space that is safe, welcoming, and respectful of LGBTQ patients and families is one way to begin addressing the health disparities that exist in this community. Below are resources to help your clinic or institution become one of these spaces.
1. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (National Academies Press: Washington, 2011).
2. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV (New York: Lambda Legal, 2010).
3. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Non-Conforming, or born with DSD: A Resource for Medical Educators. (AAMC: Washington, 2014).
4. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. (The Joint Commission: Oak Brook, Ill. 2011)
5. Ten Things: Creating Inclusive Health Care Environments for LGBT People. National LGBT Health Education Center (www.lgbthealtheducation.org).
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.
Seven myths about sex and relationships in LGBT youth
Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.
Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:
Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.1
Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.2
Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.3 This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.
Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.
Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.4 However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.
Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,5 but don’t forget that young lesbian women may have had sex with men.
Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.6 Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.
Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.
Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.
Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.7
Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,8 because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.9
So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.
The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:
• Ask, “Are your sexual partner’s male, female, or both?”
• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”
• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”
• Ask, “Have you ever had an STI, and if so, how was it treated?”
• Ask, “What do you use for birth control?” either hormonal or barrier methods.
In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.
Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”
By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.
Here are some resources on sex and relationships in LGBT youth:
• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.
• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.
• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.
References
2. National Transgender Discrimination Survey: Full Report. 2012.
3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.
4. J Youth Adolesc. 2015 Jan;44(1):211-24.
5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7.
6. Sex Transm Dis. 2010 May;37(5):335-9.
7. Sexpress: The Toronto teen survey report. 2009.
8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.
9. Can J Hum Sex. 2008;17(3):123-139.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.
Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.
Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:
Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.1
Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.2
Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.3 This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.
Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.
Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.4 However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.
Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,5 but don’t forget that young lesbian women may have had sex with men.
Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.6 Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.
Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.
Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.
Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.7
Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,8 because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.9
So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.
The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:
• Ask, “Are your sexual partner’s male, female, or both?”
• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”
• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”
• Ask, “Have you ever had an STI, and if so, how was it treated?”
• Ask, “What do you use for birth control?” either hormonal or barrier methods.
In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.
Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”
By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.
Here are some resources on sex and relationships in LGBT youth:
• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.
• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.
• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.
References
2. National Transgender Discrimination Survey: Full Report. 2012.
3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.
4. J Youth Adolesc. 2015 Jan;44(1):211-24.
5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7.
6. Sex Transm Dis. 2010 May;37(5):335-9.
7. Sexpress: The Toronto teen survey report. 2009.
8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.
9. Can J Hum Sex. 2008;17(3):123-139.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.
Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.
Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:
Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.1
Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.2
Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.3 This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.
Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.
Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.4 However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.
Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,5 but don’t forget that young lesbian women may have had sex with men.
Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.6 Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.
Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.
Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.
Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.7
Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,8 because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.9
So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.
The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:
• Ask, “Are your sexual partner’s male, female, or both?”
• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”
• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”
• Ask, “Have you ever had an STI, and if so, how was it treated?”
• Ask, “What do you use for birth control?” either hormonal or barrier methods.
In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.
Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”
By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.
Here are some resources on sex and relationships in LGBT youth:
• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.
• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.
• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.
References
2. National Transgender Discrimination Survey: Full Report. 2012.
3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.
4. J Youth Adolesc. 2015 Jan;44(1):211-24.
5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7.
6. Sex Transm Dis. 2010 May;37(5):335-9.
7. Sexpress: The Toronto teen survey report. 2009.
8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.
9. Can J Hum Sex. 2008;17(3):123-139.
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.
