Adolescent Health Care: A Practical Guide

Chapter 40

Gay, Lesbian, Bisexual and Transgender Adolescents

Eric Meininger

Gary Remafedi

Homosexuality

Homosexuality is an emotionally charged issue. It is a difficult topic to deal with, not only for the adolescent but also for his or her family and practitioner. The health care provider should be equipped to address the concerns of adolescents with a clear homosexual orientation and the fears of others, including parents who are questioning their feelings. This chapter discusses homosexuality in the context of adolescent health. Important features of counseling homosexual teens and their parents are outlined.

General Considerations and Terminology

  1. Sexual orientation: Sexual orientationrefers to an individual's attractions to the same or opposite sex. Sexual orientation is not dichotomous, and individuals tend to fall along a continuum of sexual expression and desires rather than into exclusive categories. The phrase sexual preference implies choice and should not be used in reference to sexual orientation.
  2. Gender identity: Sexual orientation should not be confused with gender identity. Gender identityrelates to an individual's innate sense of maleness or femaleness. It is felt that gender identity develops in early childhood and normally is established by age 2.5 years (Yule, 2000).
  3. Homosexuality: Although there is no absolute definition, homosexualityusually reflects “a persistent pattern of homosexual arousal accompanied by a persistent pattern of absent or weak heterosexual arousal” (Spitzer, 1981). Most homosexual individuals have a gender identity that is consistent with their biological sex.
  4. Bisexuality: A bisexualperson is attracted to both men and women. This does not preclude long-term relationships, nor does it imply promiscuity.

Complicating all of the definitions above is the fact that sexual identity, orientation, behavior, and attraction may all occur in ways that seem contradictory to some health care providers or others. Therefore, individuals may consider themselves to be heterosexual but engage in homosexual behaviors or vice versa.

Today, the term gay is usually applied to male homosexuals, but may also include lesbian females and bisexual and transgender individuals. The abbreviation GLBT is used to refer to these gay, lesbian, bisexual, and transgender populations collectively. Lesbian always refers to females. Youths who engage in sex with persons of the same gender usually identify as homosexual or bisexual, but sometimes as heterosexual, curious, or questioning.

Prevalence

Homosexuality has existed in all societies and cultures. Prevalence estimates vary according to the time, place, and different measures of homosexuality used in research. Although sexual orientation is thought to be determined before adolescence, its expression may be postponed until early adulthood or indefinitely, making it difficult to determine the actual prevalence of homosexuality during adolescence. Some adolescents who have had involuntary or coercive same-gender sex may experience confusion about their sexual orientation.

Although the prevalence, incidence, and acquisition patterns of homosexuality have been studied extensively, highly reliable data are difficult to find because of the lack of consistent clear definitions of homosexuality and the reluctance of some individuals to disclose sexual orientation information due to stigma.

  1. Adolescent population: In a large, population-based study of 35,000 junior and senior high school students in Minnesota (Remafedi et al., 1992), greater than one fourth of 12-year-old students were unsure about their sexual orientation. By 18 years of age, the figure dropped to 5% and uncertainty gave way to heterosexual or homosexual identification. Reported homosexual attractions (4.5%) exceeded fantasies, the latter being more common in girls (3.1%) than in boys (2.2%). Overall, 1.1% of students described themselves as predominantly homosexual or bisexual. The prevalence of reported homosexual experiences remained constant among girls (0.9%), but increased from 0.4% to 2.8% in boys between the ages of 12 and 18 years. Childhood and adolescent sexual behavior is not necessarily predictive of an adolescent's sexual orientation. Only about a third of the teens who reported homosexual experience or fantasies identified themselves as homosexual or bisexual. A study by Garofalo et al. (1998), based on a question added to the Massachusetts Youth Risk Behavior Survey, found that 2.5% of youth self-identified as gay, lesbian, or bisexual.

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  1. Adult population: The National Health and Social Life Survey (NHSLS) of 1992 used several dimensions of sexuality including behavior, desire, and identification (Laumann and Gagnon, 1994). The prevalence of homosexual contact since puberty was approximately 10% of men and 5% of women and 5% and 4%, respectively, had had homosexual contact since age 18 years. The numbers have been questioned in this sample, secondary to sampling methods.

Etiology and Acquisition of Homosexual Identity

Significant evidence points to fundamental biological differences between heterosexual and homosexual persons. These findings have included:

  1. Familial clustering: The clustering of homosexuality within some families has long been recognized. As compared to dizygotic twins, the greater concordance of homosexuality in monozygotic twins highlights the role of genetic constitution. Among identical twins, concordance rates for homosexuality are reported in the range of 48% to 66%. A chromosomal location has been identified that is thought to be involved in male homosexuality (Xq28), but a specific gene has not yet been identified. No clear patterns of inheritance have been established.
  2. Hormonal differences: Although heterosexual and homosexual adults have comparable levels of circulating sex steroids, it has been proposed that perinatal hormones organize and activate key areas of the brain early in life. This might contribute to the eventual development of neuroanatomical and neuropsychological functional differences related to sexual orientation.
  3. Brain structure: Genetic, hormonal, and other biological factors may influence behavior by their affect on the structure and functioning of the brain. In humans, brain regions thought to be involved in homosexuality include the interstitial nuclei of the anterior hypothalamus (designated INAH1, INAH2, INAH3, and INAH4), the supraoptic nucleus, the anterior commissure, and the corpus callosum. However, findings do vary among studies.
  4. Animal models: Same-sex domestic and sexual relationships are a common occurrence not just in humans but in other animals.

Less well understood is the way that biology interacts with the environment and experience in shaping the expression of sexual orientation. Well-designed studies have not found differences in the familial and social backgrounds of homosexual and heterosexual men and women, nor any evidence that homosexuality is related to abnormal parenting, sexual abuse, and other traumatic events. However, environment can modulate the expression of fundamental biological predisposition by influencing the social behavior and visibility of homosexual persons.

Stages of Acquisition of Homosexual Identity

Troiden (1979, 1988) outlined the following four stages in the acquisition of homosexual identity:

  1. Stage I: Sensitization. The child feels a sense of being different, without understanding the reason for these feelings. By early adolescence, there may be awareness of a different sexual orientation, including feelings and behaviors that would be considered homosexual.
  2. Stage II: Identity confusion. The adolescent begins to identify behaviors and feelings that could be considered homosexual. The idea of homosexuality may conflict with the adolescent's previously held self-identity. Some adolescents seek counseling to repair or “cure” the feelings they are having. Adolescents may experience intense social isolation or feel that there is no one else like them.
  3. Stage III: Identity assumption. The homosexual identity is adopted and, possibly, shared with others. This is a part of the process known as “coming out.”
  4. Stage IV: Commitment. The individual experiences satisfaction, self-acceptance, and an unwillingness to alter sexual identity.

A recent study (Smith et al., 2005a) found that gay and lesbian adolescents generally reported first awareness of same-sex attractions by 10 or 11 years of age, self-identification as homosexual at age 13 to 15 years, and first same-sex experiences near the time of self-identification. Self-identification usually precedes sexual debut with either male or female partners (Remafedi, 1994). Girls appear to “come out” later, in the context of a relationship; whereas boys appear to come out at a younger age, in the context of sexual encounters (Remafedi, 1994; D'Augelli, 2000).

Homophobia

The term homophobia was coined in 1967 to signify an irrationally negative attitude toward homosexuals (Weinberg, 1992). Greenberg (1988) found that two particularly prominent influences fostered homophobia in the United States—religious fundamentalism and heterosexism, the belief that heterosexuality is inherently morally superior to homosexuality. In interviews with gay, lesbian, and bisexual adolescents, D'Augelli (2000) found that 81% experienced verbal abuse; 38% had been threatened with physical harm; 15% reported a physical assault (6% with a weapon); and 16% reported a sexual assault. In the anonymous Minnesota school-based survey, gay, lesbian, and bisexual adolescents reported sexual abuse more than twice as often as the general adolescent population (Saewyc et al., 1998).

Health Concerns

Gay male, lesbian, and bisexual adolescents, like all teens, may face adverse medical consequences of either lifestyle changes, consequences of low self-esteem, or risky sexual behaviors. This is an overview of some specific issues that may arise in the care of homosexual adolescents.

Breast Cancer

The risk of breast cancer and its complications among lesbians may be heightened by nulliparity, delayed pregnancy, alcohol use, obesity, and nonuse of screening services. This is an area of ongoing research.

Eating Disorders

Gay males reported a significantly higher prevalence of poor body image, frequent dieting, binge eating, or purging than heterosexual males in a population-based survey of Minnesota schools (French et al., 1996).

Pregnancy and Parenthood

In the 1987 Minnesota Adolescent Health Survey, lesbian or bisexual women were

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equally likely to have had intercourse with men, but more likely than their heterosexual peers to report a pregnancy (12% versus 5%) (Saewyc et al., 1999). Among sexually experienced adolescents, lesbian or bisexual women were also more likely to have engaged in prostitution during the previous year (9.7% versus 1.9%).

Runaway and Homelessness

Parental rejection, abandonment, and violence contribute to the disproportionately high numbers of GLBT teens in the homeless youth community. D'Augelli et al. (1998) found that 10% of mothers and 26% of fathers of GLBT adolescents in community centers rejected their children after they revealed their sexual orientation. With damaged self-esteem and few support networks, teens living on the streets may turn to prostitution, theft, or selling drugs as a means of survival.

School Problems

Adolescents facing a hostile school environment may exhibit declining school performance or school avoidance or dropout. Conversely, they may excel in schoolwork by concentrating on their studies in lieu of social and romantic relationships (Treadway and Yoakam, 1992). Russell et al. (2001) found that middle and high school students who identified having attraction to same or both sexes were more likely to have been in a fight that resulted in a need for medical treatment, and more likely to have witnessed violence than their peers.

Substance Abuse

State-wide surveys have found that GLBT adolescents are more likely to use tobacco than their heterosexual peers (Garofalo et al., 1999). They are also significantly more likely to initiate tobacco use at a younger age (48% GLBT youth versus 23% heterosexual Massachusetts youth used cigarettes before age 13 years). A recent study by Remafedi and Carol (2005)found the GLBT youths and professionals who interact with them recommend culturally specific approaches to tobacco prevention and cessation programs.

Rosario et al. (1997) reported rates of illicit substance use that were 6.4 times higher among lesbian or bisexual girls and 4.4 times higher among gay or bisexual boys than in national samples of heterosexual peers. Because adolescents are forced to cope with the stigma of their sexual orientation at a developmental point of limited skills and resources, they may turn to alcohol or other substances as a means to escape fear and to control emotional distress. Substance use may result in unsafe sexual practices leading to sexually transmitted diseases (STDs) or human immunodeficiency virus (HIV) infections. Methamphetamine use has been increasing, and there is a strong correlation between methamphetamine use and HIV (Purcell et al., 2005; Colfax et al., 2005).

Suicide

Rates of attempted suicide among homosexual youths have been found to be consistently higher than expected in the general population of adolescents, ranging from 20% to 42% (Remafedi, 1999). As compared to gender matched heterosexual comparison groups, the risk of attempted and completed suicide appears to be especially accentuated in males. Suicide attempts often occur in proximity to “identity assumption” and may be associated with family conflict. Identified risk factors are young age at first awareness of homosexuality, experience of rejection based on sexual orientation, substance use, and perceived gender nonconformity. The severity of attempts is comparable with other adolescents. Two “psychological autopsy” studies have examined the sexual orientation of youths who had committed suicide with equivocal results.

HIV and Other STDs

The most common and serious sexually related conditions arise from unprotected penileanal intercourse. The epithelial surfaces of the fragile rectal mucosa are easily damaged during sex, facilitating the transmission of pathogens. Rectal intercourse has been shown to be the most efficient route of infection by hepatitis B virus, cytomegalovirus, and HIV.

Oral-anal or digital-anal contact can transmit enteric pathogens such as the hepatitis A virus. Unprotected oral sex can also lead to oropharyngeal disease and gonococcal and nongonococcal urethritis for the insertive partner. Certain STDs, particularly ulcerative diseases such as syphilis and herpes simplex virus infection, can facilitate the spread of HIV.

Concordance between female sexual partners suggests that bacterial vaginosis is sexually transmitted among lesbians (Berger et al., 1995). Human papilloma virus (HPV) andTrichomonas infections may also be transmitted between women. Though possible, female-to-female sexual transmission of HIV is inefficient, and women who only engage in same-sex behavior are less likely than other youths to acquire STDs in general.

Men who have sex with other men (MSM) continue to be at great risk for HIV infection. In a study of HIV risk among 15- to 22-year-old MSM in seven U.S. cities from 1994 to 1998,Valleroy et al. (2000) interviewed and tested approximately 3,500 men who were recruited in public venues. Four out of ten (41%) reported unprotected anal intercourse (UAI) in the last 6 months (range 33% to 49% across cities), and the prevalence of HIV infection was 7.2% (range 2.2% to 12.1%). In a subsequent study of 23- to 29-year-old MSM in six U.S. cities from 1998 to 2000, Valleroy et al. (2001) found 46% of 2,401 men reported UAI in the last 6 months (range 41% to 53%) and HIV prevalence was 12.3% (range 4.7% to 18%). Altogether, 77% of the men found to be HIV seropositive from 1994 to 2000 did not know they were infected. In both of these studies, HIV prevalence was found to be higher in MSM of color than among white MSM.

Health Assessment

  1. History: When evaluating adolescents for medical problems, the practitioner must elicit correct information about sexual practices. Begin by assuring the adolescent that all information will be kept in confidence (unless the adolescent poses a danger to him/herself or others). Explain that you will ask personal questions and that an honest response will help you give the best possible care. Ask questions in a nonjudgmental manner that maximizes the likelihood of an honest response. Inquiring about specific sexual practices will help determine the adolescent's risk for STDs and will direct laboratory studies. It also provides an opportunity to offer education regarding prevention of STDs and risk reduction. For those adolescents who are involved sexually, specific questions should include type of intercourse (penile-vaginal, orogenital, penile-anal, receptive or insertive, oral-anal), number of lifetime and recent

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sexual partners, use of barrier methods, prior history of STDs, symptoms suggestive of STDs, and HIV status of adolescent or their partner(s).

  1. STD screening: Not all homosexual adolescents need a full STD evaluation. If the history indicates that the teen is either not sexually active or scrupulously avoids risk, a simple physical examination may suffice. The reliability of the teen's history should be considered. If a question of veracity exists, it may be wise to offer more frequent follow-up appointments to establish a rapport and create an honest dialogue. Practitioners might routinely offer STD and HIV testing to high-risk populations such as incarcerated youth, youth in the sex industry, and institutionalized and homeless youth. Appropriate screening of the sexually active homosexual adolescent with risk factors identified during the sexual history might include a physical examination and laboratory testing for HIV, gonorrhea, chlamydia, syphilis, trichomonas, HPV infection, and other illnesses as indicated.
  2. Specific sexually transmitted diseases or conditions: GLBT adolescents are at risk of contracting the same STDs as their heterosexual counterparts. A few specific conditions related to sexual practices that are more common among gay adolescents, such as rectal HPV infection from penile-anal intercourse or pharyngeal gonorrhea from oral-genital intercourse, are elaborated later in this chapter. For more detailed information please refer to the specific chapter on diagnosis and treatment of a particular STD.
  3. Enteric illnesses: Teenagers who engage in unprotected oral or anal sex run a higher risk of contracting various enteric pathogens. Male or female adolescents who engage in anal intercourse may experience local pain, bleeding, or skin lesions due to trauma, allergy to latex or lubricants, or STDs. Persistent gastrointestinal (GI) symptoms in adolescents who engage in anal intercourse should prompt a comprehensive history and physical examination. Pathogens include, but are not limited to, Entamoeba histolytica, Giardia lamblia, Shigella, Neisseria gonorrhoeae, Treponema pallidum(syphilis), Chlamydia trachomatis, HPV (warts), and herpes simplex virus.

Diagnostic evaluation may include stool cultures for invasive bacteria and microscopic evaluation for ova and parasites. Tests for gonorrhea, chlamydia, and herpes should be obtained when proctitis is suggested by rectal discharge, tenesmus, or pain. Also consider anoscopy, anal Papanicolaou smear, and syphilis and HIV serologies.

  1. Chlamydia: Treatment for chlamydia is outlined in Chapter 62. However, clinicians should be aware of lymphogranuloma venereum (LGV), a systemic disease caused by C. trachomatis(serovars L1, L2, or L3) that occurs only rarely in the United States. As of September, 2004, the Netherlands saw a 19-fold increase in confirmed cases among MSM. Most cases were also coinfected with HIV. LGV should be considered in young MSM who have proctitis, proctocolitis, or painful inguinal lymphadenopathy as a presenting complaint (Centers for Disease Control and Prevention [CDC], 2004b).
  2. Gonorrhea: Gonococcal infections may be asymptomatic or associated with pharyngitis, urethritis, and proctitis. Treatment for gonorrhea is outlined in Chapter 61. Clinicians should be aware of increasing fluoroquinolone-resistant N. gonorrhoeae(prevalence of 5% or more) in MSM. As of 2007, the CDC no longer recommends fluoroquinolones in treating any gonococcal infections.
  3. Syphilis: Since the mid 1990s, there has been growing concern about a resurgence of risky sexual behavior in MSM, possibly leading to an increase in HIV transmission. Reviews of sexual behavior data suggest that rates of UAI have been increasing among MSM. There have been outbreaks of syphilis (CDC, 2003) and gonorrhea among MSM in U.S. cities and increases in newly diagnosed HIV infections among MSM from 1999 to 2002 (Guenther-Grey et al., 2005).

Detecting the primary lesion of syphilis at the anus, where it may not be seen or felt, can be difficult. Although generally painless, rectal syphilis can cause discomfort or may appear as an atypical lesion with shaggy borders, resembling carcinoma. Regular syphilis screening is recommended for sexually active MSM. There is evidence that coinfection with HIV may alter the course of syphilis. Syphilis in HIV-seropositive individuals may not respond to traditional therapy or may have an accelerated course. Evaluation and treatment for syphilis is outlined in Chapter 64.

  1. Hepatitis: Historically, there has been a higher prevalence of hepatitis B in the gay male community than in the general population. The American Academy of Pediatrics (AAP) recommends routine hepatitis B vaccination for all children. Hepatitis A can be transmitted by the fecal-oral route during orogenital and oral-anal sex. Because of this and the potential morbidity among infected adults, the hepatitis A vaccine series is recommended for all MSM. Hepatitis is discussed in more detail in Chapter 30.
  2. Cytomegalovirus infection: As many as 80% of homosexual males who engage in sex with multiple partners will acquire cytomegalovirus within a year (Mintz et al., 1983). This infection is largely asymptomatic but may lead to a severe mononucleosis-like illness, particularly in an immunosuppressed HIV-seropositive teen.
  3. HPV infection: Condyloma acuminatum (genital warts) can be found on the penis, vagina, or rectal area. Management of internal warts is complicated and should be carried out in consultation with an expert. Treatment for condyloma is outlined in Chapter 66. HPV is the cause of cervical dysplasia, which can be a risk factor for cervical cancer. It can also cause dysplasia in the anal or rectal mucosa increasing the risk for anal or rectal carcinoma. All sexually active female patients, whether they identify as heterosexual, bisexual, or lesbian, should be screened routinely with a Papanicolaou smear (guidelines can be found in Chapter 54). Anal Papanicolaou smears can also be used to screen for anal condyloma. The benefit of screening for anal carcinoma is an area of ongoing research. A vaccine for the prevention of HPV infections is now available for females between the ages of 9 and 26.
  4. Herpes simplex: Herpes simplex infections of the penis, vagina, mouth, or rectum can occur. Findings associated with herpes simplex proctitis include fever, difficulty with urination or defecation, sacral

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paresthesias, inguinal adenopathy, severe anorectal pain, tenesmus, constipation, perianal ulcerations, and the presence of diffuse ulcerations or vesicular or pustular lesions in the distal 5 cm of the rectum. Treatment of herpes simplex is outlined in Chapter 65.

  1. HIV infection: Acquired immunodeficiency syndrome (AIDS) and HIV are discussed further in Chapter 31. Because of limited social networks, meeting sexual partners through the Internet has become an increasingly popular and potentially risky behavior for MSM. Benotsch et al. (2002) found that one third of MSM met a sexual partner on-line. GLBT youth may be at particular risk for HIV exposure because of their relative inexperience and weaker position of power in negotiating drug use and condoms. Drug use (e.g., methamphetamines, marijuana, ecstasy, and others) has been shown to increase the likelihood of UAI in MSM. Recommend a barrier method of protection for all sexually active teens. Discuss Internet and drug usages with the adolescent and recommend the following safer sexual practices:
  • Abstain from sex or risky sexual practices such as anal intercourse.
  • Reduce numbers of sexual partners. Screen for Internet use as a means of meeting new partners.
  • Use condoms or barriers consistently during insertive and receptive oral, anal, and vaginal sex.
  • Use latex—not natural lambskin—condoms, because the latter have been shown to be potentially porous. Polyurethane condoms are an acceptable, albeit more expensive, alternative for teens with a sensitivity to latex.
  • Lubricants should be water-based products, rather than oil-based ones that can deteriorate condoms and contribute to pruritus ani.
  • Avoid sharing needles. If needles must be used, they should be clean, fresh from a sealed pack, or flushed with household bleach and then water.
  • Avoid substance use during sex. Brainstorm harm-reduction techniques to increase the likelihood of condom use during sex.

Counseling Issues

The AAP recognizes the physician's responsibility to provide health care for homosexual adolescents and for those young individuals struggling with issues of sexual expression. The removal of homosexuality from the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1973 signaled a change in our understanding and counseling of homosexual teens and their parents.

Given the opportunity to grow up in a supportive environment, most gay and lesbian adolescents are no more likely to experience serious mental health problems than the general adolescent population (Gonsiorek, 1988). Homophobia engenders guilt, shame, and psychological problems. Practitioners must also be prepared to counsel worried parents in their attempt to understand their child. If the health care provider is unable to accept homosexuality as healthy and normal, he or she should be prepared to refer the adolescent to an appropriate resource.

Counseling the Teen

  1. Create an open environment in which the teen feels comfortable discussing issues of sexuality.
  2. Do not minimize the adolescent's concerns regarding sexual orientation. Stating that “it's just a phase” may actually intensify the teen's confusion.
  3. Discussing homosexuality with teens will not make them homosexual.
  4. Assure the teen that homosexuality is a normal variation of sexual orientation and that sexual orientation is biologically driven.
  5. Do not expect teens to define their sexual orientation prematurely. Sexual orientation unfolds during adolescence. Assuring them that questions about their sexual orientation will resolve over time may take some of the urgency out of the issue, “Am I, or am I not?” Remember, health care providers are not responsible for labeling, or even identifying youth who are nonheterosexual (American Academy of Pediatrics, 2004).
  6. The position of the APA is that conversion therapy (i.e., attempts to repair or “cure” them of homosexuality) is not useful and may be damaging. In a review of outcomes,Haldeman (1991) found that attempts to replace homosexual fantasies with heterosexual ones were unsuccessful among men who had not experienced sexual attraction to women. Such attempts may contribute to guilt, low self-esteem, and psychological problems.
  7. Irrespective of whether adolescents have resolved uncertainty about their sexual orientation, helping to prevent the spread of HIV/AIDS infection is of paramount importance. This is a prime reason to inquire about a teen's sexual practices.
  8. Not all homosexual teens experience difficulties with their orientation. As with other healthy adolescents, well-adjusted homosexual individuals need sensitive and informed health care services. Some individuals will appreciate the opportunity to discuss their unique experiences or concerns as GLBT youth.

Counseling Concerned Parents

The following are some suggestions for helping families:

  1. Help parents explore and address their feelings of anger, fear, shame, guilt, or grief.
  2. Offer correct information about homosexuality.
  3. Explain that not every emotional problem manifested by a teen is a result of his or her sexual orientation.
  4. Challenge society's dichotomous belief that homosexuality is bad and that heterosexuality is good.
  5. Explore religious beliefs and provide appropriate referrals. Affirming groups exist in most faiths and religious denominations.
  6. Discuss HIV/AIDS prevention with parents. Some parents automatically associate homosexuality with illness.
  7. Supplement counseling with referrals to support groups such as Parents and Friends of Lesbians and Gays (PFLAG). Another useful resource is the National Youth Advocacy Coalition (NYAC), which maintains a directory of local resources. The addresses of both organizations can be found in the Resources section of this chapter.
  8. Finally, help parents understand that the adolescent who just “came out” is the same teen who sat before them before the disclosure. The adolescent's main need has been, is, and will always be love and acceptance.

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Transgender Adolescents

If homosexuality is an emotionally charged issue, issues of gender identity are even more so. The available literature on transgender adolescents and gender identity is limited, but growing (Boehmer, 2002). This section discusses gender identity in the context of adolescent health, and highlights important points for counseling teens and their parents.

General Considerations and Terminology

The AAP (2004) defined gender identity as a person's innate sense of maleness or femaleness. A person whose assigned sex at birth does not match gender identity is transgender. Transitioning is the process of changing one's appearance to better reflect one's gender identity. A transsexual is someone who has done something—either medically, surgically, or merely cosmetically—to express the gender with which they identify. Transgender is a term that captures diverse individuals, including persons who have disclosed their gender identity to others, started mental health counseling, initiated medical hormone management, undergone sexual reassignment surgery (SRS), or some combination thereof. It is different from the paraphilia of cross-dressing or transvestitism (DSM 302.3), involving sexual pleasure from dressing or wearing clothes of the opposite gender. Although transgender individuals are typically identified by health professionals as male-to-female (conventionally, MTF) or female-to-male (FTM), affected youth may not even identify as transgender—but only as a male or a female.

Gender identity is inherently different from sexual orientation. However, from a sociocultural perspective, transgender persons often identify with GLBT communities. Some transgender individuals actually identify themselves as gay, lesbian, or bisexual (Clements-Nolle et al., 2001), although most have a heterosexual orientation—that is, opposite gender of their sex of conviction (Smith et al., 2005). Historically, individuals with ambiguous genitalia were not described as transgender, but as intersex. Some progressive organizations have started using the acronym GLBTI to acknowledge that intersexed persons may face similar challenges as others within the group.

Unlike homosexuality, which was removed from the Diagnostic and Statistical Manual as a mental illness, the diagnosis of gender identity disorder (GID) has persisted—hopefully, only to facilitate access to therapy and counseling specific to gender and transitioning issues, and to enable individuals to receive medical and surgical management of their gender identity. There are three diagnoses related to gender identity—Gender Identity Disorder of Childhood (DSM 302.6), Gender Identity Disorder of Adolescence and Adulthood (DSM 302.85), and Gender Identity Disorder, Not Otherwise Specified (NOS) (also DSM 302.6). Because most children with GID of childhood grow up to be homosexual (Zuger, 1984), experts have questioned the validity, utility, and ethicality of its diagnosis and treatment in children. A subset of children who experience conflict between their assigned sex and core gender identity (as opposed to gender role), may eventually identify as transgender. Medical treatment is rarely considered in prepubertal children with GID. Because adolescence is a period of identity development, there is some concern that a child with nonconforming gender role may be prematurely and/or erroneously considered transgender (Smith et al., 2002).

Prevalence

The most recent data from the Netherlands suggests that 1 in 11,900 males and 1 in 30,400 females (Harry Benjamin International Gender Dysphoria Association [HBIGDA], 2001) meet the criteria for GID. However, little is known about the actual prevalence of transgender individuals in populations. Transgender individuals may identify only as male or female, confounding epidemiological research. A measure of the success of the transition process is how well one feels authentic and comfortable with one's gender identity.

Etiology

Multiple studies have attempted to identify biological differences between transgender and nontransgender individuals. Except for intersexuality, variant gender identity is not necessarily associated with endocrinological disorders (Wilson, 2003), although some experts disagree.

Transphobia

Transgender youths are likely to experience homophobia because of widespread societal misunderstanding of gender identity. Like the term, homophobia, transphobia describes an individual and societal prejudice and stigma against transgender individuals, which likely contributes to some of the negative health outcomes that transgender youth experience.

Health Concerns

As a population with health disparities, transgender adolescents are at risk for multiple health problems.

Cancer

Little is known about the risks of malignancy in transgender individuals. Health educators may not perceive someone who is MTF as a woman and may neglect to educate about breast self examination. Likewise, an FTM individual who has not had chest reconstruction, but who passes as a man, also may not receive appropriate instruction.

Pregnancy

Transgender youth may be perceived to be at low risk for pregnancy. However, it is important to ask about sexual practices and the biological gender of partners. A gay-identified FTM who has intercourse with males is at risk for pregnancy; and it is important to discuss contraception with persons who might ovulate.

Smoking

Transgender youth appear to have a higher prevalence of smoking compared with other adolescents (Cardona et al., 2005; Remafedi, in press). Some use tobacco to cope with the stress associated with a stigmatized identity. MTF youth may identify with glamorous women seen in advertisements. Alternatively, FTM teens

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may smoke to appear more masculine and to lower their voices (Cardona et al., 2005).

HIV

Injection hormones are available illicitly. Silicone also may be injected to enhance features. Some youth, especially minors, may initiate self-treatment without medical supervision and share needles with friends. Because of employment discrimination, some young people turn to prostitution as a means to pay for therapy, hormones, or surgery (31% of adult FTM and 80% of adult MTF [Clements-Nolle et al., 2001]). For some, prostitution is related to stigma and is a validation of gender identity. Probably due to a combination of these factors, black transgender MTF youth have been identified as a subgroup with extraordinarily high rates of HIV, 63% in one study of Californians (Clements-Nolle et al., 2001).

Runaway and Homelessness

For many of the same reasons as GLB youth, transgender youth have an increased likelihood of becoming homeless.

School Problems

Transgender youth report high rates of verbal and physical abuse in school. One qualitative study in Philadelphia found that 96% of transgender youth reported being verbally harassed; 83% reported physical harassment; and 75% dropped out of school (Sausa, 2003).

Substance Abuse

Substance abuse has been identified as a problem in the transgender adult community (Nemoto et al., 1999). No definitive studies of youth are available.

Suicide

Transgender youth may be at an even greater risk of attempted suicide than GLB youth (Bockting et al., 2005). Clements-Noll et al. (2001) found that 62% of MTF and 55% of FTM transgender adults met the criteria for depression. Thirty-two percent of both populations had attempted suicide.

Hepatitis

Transgender youth may be at an increased risk for hepatitis B and C if they are using injection hormones and sharing needles. One survey of MTF clients reported a high prevalence of hepatitis B in a pubic health STD clinic (Moriarty et al., 1998). MTF who have sex with men face the same risks as other MSM.

Mental Health Concerns

Teens who are dealing with the stress of gender dysphoria often lack resources for housing, medical care, and basic living expenses. The time delay between “coming out” as transgender and transitioning medically is a very unique stressor impacting upon their mental health. Age-related emotional immaturity can adversely impact identity formation and decision-making skills.

Counseling the Teen

  1. Create an open environment where adolescents feel comfortable discussing issues that trouble them.
  2. Do not make assumptions about names or pronouns. If unsure, ask which pronoun or name the young person prefers.
  3. Do not trivialize concerns about gender identity. Acknowledging the adolescent's concerns can bring significant relief.
  4. When youngsters express distress about gender identity, assure them that fluidity can be normal and that they do not need to find immediate resolution.
  5. Puberty for transgender teens can be socially, emotionally, and physically stressful. It can feel as if the body is changing against one's will. Know the local resources for endocrinological treatment and mental health counseling and support.
  6. Because of discomfort with certain body parts, both transgender individuals and their health care providers may avoid examining the breasts and genitals. Acknowledge the discomfort and remind the adolescent that it is important to continue comprehensive examinations.
  7. Encourage adolescents to take advantage of professional resources. The Harry Benjamin Standards of Care (Harry Benjamin International Gender Dysphoria Association [HBIGDA], 2001), the most widely recognized approach to transgender management, encourage mental health evaluation and ongoing counseling as part of the medical and surgical transition.

Counseling Concerned Parents

  1. Help parents explore and address their feelings of anger, fear, shame, guilt, or grief.
  2. Reassure them that they did not cause gender confusion.
  3. Offer support resources for parents to connect with other parents who have transgender children. PFLAG chapters are often good places to start.
  4. Practitioners should be prepared to provide Web sites and printed resources for teens and their parents, and referrals for mental health assessment, diagnosis, and experienced counseling.

Medical and Surgical Management of the Transgender Teen

A discussion of the appropriate medical and surgical management of transgender youth is beyond the scope of this chapter. However, helpful references appear in the Resourcessection. The dilemma facing practitioners is to provide help with transitioning while avoiding irrevocable medical or surgical interventions that might cause regret. Young adolescents with a strong transgender identity may experience growing social anxiety or depression as their bodies rapidly change away from their gender conviction. In such situations, delaying treatment may have a deleterious impact on school performance, peer interactions, and romantic relationships. In addition, some of the normal physical transformations of puberty, such as breast development or deepening voice, may leave unerasable traces or may commit the young adult to future treatments that have potential morbidities. In such cases, some experts (Harry Benjamin International Gender Dysphoria Association [HBIGDA], 2001) recommend reversible interventions to delay the physical changes of puberty long enough to allow parents and adolescents to make an informed decision about treatment options. On the basis of a number of follow-up studies of adolescents and adults, unfavorable outcomes are related to starting

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sexual reassignment too late, rather than too early (Cohen-Kettenis and Gooren, 1999; Smith et al., 2001).

The authors would like to acknowledge the assistance provided by Walter Bockting, Ph.D., Janet Bystrom, MA, and Alex Nelson in the section on transgender adolescents.

Resources

Federation of Parents and Friends of Lesbians and Gays (PFLAG)
1726 M St, NW, Suite 400
Washington, DC 20036
202-467-8180 Fax 202-467-8194 www.pflag.org.

A national organization of parent support groups organized in local chapters. A good resource of information and reading lists for parents. PFLAG's focus is advocacy, support, and education.

National Gay and Lesbian Task Force (NGLTF)
1325 Massachusetts Ave, NW, Suite 600, Washington, DC 20005
202-393-5177 Fax 202-393-2241 www.thetaskforce.org.

A national organization working for the civil rights of GLBT people. It has an extensive library of public policy summaries available on its Web site.

Bisexual Resource Center (BRC)
P.O. Box 1026, Boston, MA 02117
617-424-9595 www.biresource.org.

An organization providing information, programming, speakers, and a historical archive on bisexuality. The Web site has many links to bisexual resources across the Internet.

Gay and Lesbian National Help Center (GLNH) 800-246-PRIDE www.glnh.org.

An organization providing nationwide toll-free peer counseling, information, and referrals. The Web site includes a collection of resources arranged by region. The 800-246-PRIDE line is a national youth talk line providing peer counseling and information.

Advocates for Youth
2000 M Street, NW, Suite 750, Washington, DC 20036
202-419-3420 Fax 202-419-1448 www.youthresource.com.

An international advocacy group creating programs to help youth make responsible decisions about their sexual health. The Web site is youth oriented and has information forums on school, disabilities, HIV-seropositive youth, and youth of color.

National Youth Advocacy Coalition (NYAC)
1638 R Street, NW, Suite 300, Washington, DC 20009
202-319-7596 Fax 202-319-7365 www.nyacyouth.org.

National network and clearinghouse whose focus is advocacy in public policy. A good contact for up to date information on local resources and support. The Web site has a resource directory organized by region.

The World Professional Association for Transgender Health (WPATH)
1300 South Second Street, Suite 180, Minneapolis, MN 55454
612-624-9397 www.wpath.org.

A professional organization dedicated to advancing the understanding and treatment of GIDs.

Books for Teens, Parents, and Health Care Providers

Age 6–12 Years

Harris RH. It's perfectly normal. Cambridge, MA: Candlewick, 1994. (Book about sexuality and growing up with a nonjudgmental section on homosexuality. Includes same-sex couples in its illustrations.)

Newman L. Heather has two mommies. Boston: Alyson, 1989. (A simple straightforward story of a little girl named Heather and her two lesbian mothers.)

Salat C. Living in secret. New York: Bantam, 1993. (Eleven-year-old Amelia runs away with her mother and her mother's lover when her father will not let them be together.)

Willhoite M. Daddy's roommate. Boston: Alyson, 1990. (A young boy describes his father's relationship with his roommate, Frank, and his healthy, affectionate relationship with these two men.)

Age 12 Years and Older

Bauer MD, ed. Am I blue? Coming out from the silence. New York: Harper Collins, 1994. (Collection of stories featuring gay characters by popular young adult writers.)

Beam J, ed. In the life: a black gay anthology. Boston: Alyson, 1986. (Writers and artists explore what it means to be doubly different—black and gay—in contemporary America.)

Howe J. Totally Joe. New York: Atheneum, 2005. (Written as a school assignment, 12-year-old Joe shares stories of his friends, family, and relationships in the context of being gay.)

Hutchins L, Kaahumanu L, eds. Bi any other name: bisexual people speak out. Boston: Alyson, 1991. (Anthology of prose, poetry, art, and essays by bisexual artists and writers.)

McClain LJ. No big deal. New York: Lodestar, 1994. (A thirteen-year-old girl is forced into action when her mother joins a campaign to get her favorite teacher fired because of rumors that he's gay.)

Nelson T. Earthshine. New York: Orchard, 1994. (Twelve-year-old Slim narrates the story of her life with her father and his lover during the last few months before the lover's death.)

Peters JA. Luna. New York: Time Warner Book Group, 2004. (Told by his brother, this is the story of a young man's struggle with gender identity, and his family's struggle to accept Luna for who she is.)

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Sanchez A. Rainbow boys. New York: Simon and Schuster, 2001. (First in a series chronicling 3 gay high school friends and their adventures. Also Rainbow High, 2003, and Rainbow Road, 2005.)

Older Teens

Clark D. Loving someone gay. Berkeley, CA: Ten Speed Press, 1997. (Insight into the interaction of gay people with each other, their families, and their loved ones.)

Cowan T. Gay men and women who enriched the world. Boston: Alyson, 1996. (Biographies of 47 gay men and women who offered outstanding contributions in different fields.)

Feinberg L. Stone butch blues: a novel. Ithaca, NY: Firebrand Books, 1993. (A novel chronicling the life of a female to male transgender person in the context of the gay pride movement.)

Fricke A. Reflections of a rock lobster. Boston: Alyson Publishing, 1981. (Personal account written by a young man who made national headlines by bringing a male date to his high school prom.)

Heron A. Two teenagers in twenty, writings by gay and lesbian youth. Boston: Alyson Publications, 1994. (A collection of letters and essays contributed by gay and lesbian teens.)

Marcus E. Is it a choice? Answers to the 300 most frequently asked questions about gays and lesbians. San Francisco: HarperCollins, 1999. (Organized into 20 sections covering issues such as coming out, religion, aging, military, and education.)

Mastoon A. Shared heart: portraits and stories celebrating lesbian, gay, and bisexual young people. New York: William Morrow, 1997. (Photographic collection of gay, lesbian, bisexual, and transgender adolescents in the context of their families and schools.)

Reid J. The best little boy in the world. New York: Ballantine Books, 1976. (Humorous story about growing up gay in a straight world.)

Sarton M. The education of Harriet Hatfield: a novel. New York: WW Norton, 1989. (A story about an elderly woman who gradually comes out after her partner of 30 years dies.)

Parents

Boylan JF. She's not there: a life in two genders. New York: Broadway Books, 2003. (An articulate autobiography written by a MTF transgender college literature professor.)

Day FA. Lesbian and gay voices: an annotated bibliography and guide to literature for children and young adults. Westport, CO: Greenwood Press, 2000. (A resource compiled by a retired teacher of current literature for schools and parents.)

Fairchild B, Hayward N. Now that you know: what every parent should know about homosexuality. San Diego: Harcourt Brace, 1989. (A guide written by parents of gay children.)

Helminiak D. What the Bible really says about homosexuality. San Francisco: Alamo Square Press, 1995. (The author discusses research into those biblical texts that have been considered to relate to homosexuality.)

Professionals

Gonsiorek JC, ed. A guide to psychotherapy with gay and lesbian clients. Bingingham, NY: Harrington Park, 1990. (Affirmative psychotherapeutic models.)

Harbeck KM, ed. Coming out of the classroom closet: gay and lesbian students, teachers, and curricula. New York: Haworth Press, 1992. (A collection of research on homosexuality and education.)

Harry Benjamin Standards of care for gender identity disorder, 6th version. Available online at http://wpath.org/Documents2/socv6.pdf. (The definitive resource for transgender adolescents and adults.)

Ryan C, Futterman D. Lesbian and gay youth: care and counseling. New York: Columbia University Press, 1998. (Comprehensive guide on medical, psychological, and support needs of lesbian and gay youth. Recommended for medical providers, counselors, youth advocates, and parents.)

Tom Waddell Health Center protocols for hormonal reassignment of gender. Available online at http://www.dph.sf.ca.us/chn/HlthCtrs/HlthCtrDocs/TransGendprotocols.pdf. (An introduction to the risks, benefits, monitoring, and dosing of hormone therapy for transgender individuals.)

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Berger BJ, Kolton S, Zenilman J, et al. Bacterial vaginosis in lesbians: a sexually transmitted disease. Clin Infect Dis 1995; 21:1402.

Boehmer U. Twenty years of public health research: inclusion of lesbian, gay, bisexual, and transgender populations. Am J Public Health 2002;92:1125.

Cardona A, Hastings P, Zemsky B. Creating an effective tobacco plan for Minnesota's gay, lesbian, bisexual and transgender communities. Minneapolis, MN: Rainbow Health Initiative, 2005.

Centers for Disease Control and Prevention (CDC). Increases in fluoroquinolone-resistant Neisseria gonorrhoeae among men who have sex with men–United States, 2003, and revised recommendations for gonorrhea treatment, 2004. MMWR Morb Mortal Wkly Rep 2004a;53:335.

Centers for Disease Control and Prevention (CDC). Lymphogranuloma venereum among men who have sex with men—Netherlands, 2003–2004. MMWR Morb Mortal Wkly Rep2004b;53:985.

Centers for Disease Control and Prevention (CDC). Trends in reportable sexually transmitted diseases in the United States, 2003: national data on chlamydia, gonorrhea, and syphilis. Retrieved from http://www.cdc.gov/std/stats/trends2003.htm, on 10/30/2005, 2005.

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