Sheran M. Simo
Things aren’t always the way they appear. Judgments are made on a daily basis regarding every aspect of a person’s life, including lifestyle, religious beliefs, and sexual orientation. As is often the case in the primary healthcare setting, the initial reason that brings an individual in for a health visit may evolve into something completely different as the visit progresses.
1. Identify lesbian, gay, bisexual, and transgendered (LGBT)–sensitive questions to ask your patients.
2. Identify and become familiar with health issues specific to adolescent LGBT youth.
3. Identify risk factors such as sexually transmitted diseases (STDs), mental health disorders, and violence that LGBT youth may experience.
4. Become familiar with resources available in the community specific to LGBT youth.
Case Presentation and Discussion
Fifteen-year-old Cassandra Stanley is brought to your office by her mother. According to Mrs. Stanley, she would like you to initiate birth control for her daughter. As the story unfolds, you learn that Cassandra is the youngest of three daughters, 8 years younger than her next older sibling. Mom states that she had initiated birth control for Cassandra’s sisters and neither of them became pregnant prior to finishing school and getting married. She hopes to provide the same means of protection for Cassandra. As you look to Cassandra to initiate the conversation, you notice that Cassandra appears very upset. She expresses to her mother that she’s already told her that she doesn’t want to be on birth control so this visit is pointless!
You realize very quickly that you have a stressful situation on your hands and ask Mom to step out of the room to allow you to get to know Cassandra a little better and talk with her in private as you do with all your teen patients. During the course of your conversation, Cassandra blurts out, “My mom wants me to take birth control because she thinks I want to have sex with boys.” As you question her further, she relates, “I’m in love with my best friend, and she can’t get me pregnant!” Cassandra reveals that she has “always known I liked girls” and “can’t imagine ever being with a boy.”
What information do you need to recall for this situation?
Because of the delicate nature of this situation, it is important for the healthcare provider (HCP) to be sensitive to the teen’s feelings and concerns. In order to promote this type of communication, the provider is encouraged to ask open-ended questions. Asking open-ended questions promotes conversation more readily and helps the teen to think more clearly about what it is that they want to discuss or what questions they need answered, such as, “What questions about being with your partner have come to mind as you’ve begun to think about being sexually active?” or “What questions would you like to ask me as you begin your sexual relationship?” Asking adolescents closed-ended questions such as “Do you understand?” or “Do you have any questions?” will limit the discussion.
It is also important for the practitioner to be aware of what it means when a female describes herself as a woman-loving woman or lesbian, or a male describes himself as a male-loving male or gay. Sexual orientation describes the direction a person’s emotional connections, attractions, and sexual activity lean toward. Attractions may be toward the same sex (homosexual, gay, lesbian), the opposite sex (heterosexual), or toward both sexes (bisexual). Table 15-1 defines these different sexual orientations.
It is important for the HCP to consider several factors when working with adolescents who are deliberating about their own sexual orientation, especially when they believe they are or may be homosexual.
• Adolescents usually establish their sexual identity by the time they reach adolescence, even if they have not had an opportunity to act on it.
• Sexual orientation cannot be changed; it is deeply ingrained within children’s makeup. Very often the fact that children or adolescents are gay remains hidden from family and friends, and is often denied by the teens themselves.
• Sexual orientation appears to be a biological phenomenon. Only rarely, if ever, is sexual orientation caused by personal experiences and environment (American Academy of Pediatrics, 1999), although heredity seems to also have a place.
Table 15–1 Definitions
• Lesbian: A woman who finds an emotional, sexual, and romantic connection only with another woman.
• Gay: Very often used to describe people attracted to members of the same sex, though gay is most often used to refer only to men who are attracted to other men.
• Homosexuality: Sexual and emotional attraction to a member of the same sex.
• Bisexual: Sexual and emotional attraction by one toward members of either sex.
• Transsexual: One who identifies with a gender different from the physical body in which they were born, or were assigned to if there was ambiguity of the sexual organs at birth.
• Despite increased knowledge and information about being gay or lesbian, teens still have many concerns. These include (American Academy of Child and Adolescent Psychiatry, 1997):
Feeling different from peers
Feeling guilty about their sexual orientation
Worrying about the response from their families and loved ones
Being teased and ridiculed by their peers
Worrying about AIDS, HIV infection, and other STDs
Fearing discrimination when joining clubs or sports, seeking admission to college, and finding employment
Fearing rejection and harassment by others
What health issues might you see in LGBT adolescents?
Health Issues Related to LGBT Adolescents
Health Risk Behaviors
LGBT adolescents are at a higher risk for increased use of tobacco, drugs, and alcohol than their heterosexual counterparts, due to increases in social, identity, legal, and discriminatory stressors.
Sexually Transmitted Disease Risks
Because of certain sexual practices performed by LGBT individuals, they are potentially at risk for STDs. These practices include anal and/or vaginal coitus, oral sex, and casual or multiple sex partners. Sexually transmitted infections can include herpes, chlamydia, gonorrhea, trichomoniasis, syphilis, genital warts (HPV), human immunodeficiency virus (HIV), and hepatitis. Furthermore, even though adolescents identify as LGBT, they may not necessarily limit their sexual practices to those of their identified sexual preference. As such, they may be at risk for any or all of the same consequences as their heterosexual counterparts.
Mental Health and Violence Risks
As a result of perceived or real homophobia and increases in other stressors, LGBT adolescents are more likely to suffer from depression. LGBT adolescents also are at risk for violence, both from society at large and in their partnered relationships. It is a misperception to assume that persons in LGBT relationships do not suffer from intimate partner violence.
LGBT adolescents (and adults) may avoid medical care and appropriate health screenings because of a misperception that they are only necessary for heterosexuals. For example, lesbian or transgendered nonsurgical female to males (FTMs) may avoid getting regular Pap smears because they believe they aren’t at risk for cervical cancer or choose to ignore the existence of sexual organs they were originally born with. Lesbians and FTM transgendered individuals may be at higher risk for breast cancer because they may be less likely to bear children or lactate.
Lesbians appear to have a better body image; they are often less concerned with being thin for society’s sake and as a result may be more inclined to be overweight or obese than heterosexual women. This, in turn, increases the risk of health problems associated with obesity, including diabetes, heart disease, hypertension, and cancers of the uterus, ovaries, breast, and colon.
Lesbians are less likely to use oral contraceptives and other forms of hormonal birth control and so are at greater risk for endometrial, breast, and ovarian cancers.
How will you respond to what Cassandra has told you?
When her mother leaves the room, you let Cassandra know that you can see that she and her mom have a difference of opinion on whether she should be on birth control. At this point, you question whether Cassandra has told her mother that she is a lesbian, and encourage her to talk to her mother when she reveals that she has not.
You keep in mind that although teenagers may not respond fully with eye contact or verbally, they “hear” everything said to them. It is important to convey a sense of acceptance of her from the beginning of the encounter.
You reassure Cassandra that people not only have different preferences in sex partners, but also have a variety of ways of enacting their sexual orientation and that you respect people’s individuality. It’s essential to let her know that you are here to provide the kind of information and support she needs to stay healthy and feel positive about herself, to answer questions, and to provide a place to talk personally about anything that affects her body, just as you do for all of your patients.
What important points would you consider during your discussion with Cassandra?
The following points would be important to discuss with Cassandra:
Identify that you are aware of a conflict between the patient and her mom. Use a respectful, straightforward, “coaching” approach allowing space for thinking between points.
Stress to the patient that sexuality is a very individual thing; that not only are there varying sexual orientations but that even within those, people have their own personal ways of acting that out and that this must be respected and will be respected by you, the healthcare practitioner.
Encourage her to keep in mind that others are not always as courageous and honest; for example, a bisexual or lesbian woman may be sleeping with a man or using needle drugs and not admit it. Stress that this is why same-sex sexual encounters should even include safe sex between women.
Ask her what she knows about how to have safer same-sex encounters, where to get the supplies, and specifically how to use them. Tell her that if she should need coaching about how to talk to another woman about using safe sex to please come back and talk with you whenever she needs to.
Adolescents may move through several phases of sexual experimentation before settling on an orientation. In addition, you realize that to speak of this directly at this encounter could give Cassandra the impression that you do not take her current choice seriously. Instead, you decide to ask from the standpoint of a routine STD screening and ask her if she has ever had sex with a male partner and whether it was ever sex without a condom. If she has had unprotected sex with a male, then you might ask her if you can test her today for STDs as part of her routine “well woman” exam.
Sexual Expression of Adolescents
In 2006, the U.S. Census Bureau, through an American Community Survey, established that there are approximately 21.6 to 21.7 million adolescents of both genders between the ages of 15 and 19. When evaluating the percentage of those who may present in primary care clinics with issues related to gay or lesbian sexual health and accompanying psychosocial issues, social scientists frequently use the rule of thumb that 1 in 10 adolescents is LGBT or otherwise nonheterosexually identified (U.S. Census Bureau, 2006). Closely supporting this estimate, the Kinsey Institute for Sexual Research sponsored a national survey in 2005 that identified nonheterosexual percentages in the American population as 1 in 8 (Kinsey Institute, 2005).
Although it is important to consider that many teens experiment sexually and do not necessarily form a complete sexual orientation until adulthood, a substantial percentage of adolescents who experiment with same-sex partners will eventually identify themselves as gay, lesbian, bisexual, or transgendered. According to the 2005 Kinsey Institute study:
• Among men ages 18–44, 2.3% considered themselves homosexual, 1.8% identified as bisexual, and 3.9% indicated that they identified as “something else.”
• Among women between the ages of 18 and 44, 1.3% identified as homosexual, 2.8% considered themselves bisexual, and 3.8% identified as “something else.”
Based on these data, there are at least 2.7 million teens with potential to be involved with same-sex partners around the United States. It is important for healthcare providers to be aware of the needs of this segment of the population, as well as to be prepared to educate and be a source of healthy role modeling for this substantial primary care patient population.
The Kinsey Institute’s (2005) national survey also found that of the teens surveyed, there was about a one in three chance of having engaged in sexual activity with at least one partner at some point in their lives (Kinsey Institute, 2005):
• The findings for men of all sexual orientations ages 15–19 years old: 45.1% had not had sexual contact with a partner, 29.7% reported one partner in 12 months, and 21.8% reported two or more partners in the 12-month period. Men in this same age group reported that 2.4% had engaged in same-sex contact in the previous 12 months, and 4.5% had same-sex contact at some point in their history.
• The findings for women of all sexual orientations ages 15–19: 42.9% had not had sexual contact with a partner, 30.5% had sexual contact with one partner, and 16.8% had sexual contact with two or more partners in the last 12 months. For women in this same age group, 2.7% reported having engaged in a same-sex contact during the previous 12 months; 7.7% had same-sex contact at some point in their history.
You ask Cassandra if she and this (or any other) female partner have had sexual relations beyond kissing. This will create an opening to ask her what safe-sex practices she knows for woman–woman sex. (If the patient were a male, you would ask what he knows about safe-sex practices for male–male sex.)
What are the risks of contracting a sexually transmitted infection?
STD prevention and identification are factors in the health care and education of all adolescents. Almost half of the 19 million new cases of STDs each year occur among adolescents and young adults between the ages of 15 and 24.
Clinicians need to be able to provide appropriate health screening services and education for LGBT youth in primary care settings because there may be no available resources for LGBT youth within the community that can provide these services in an atmosphere of respect and trust. If the patient fears a breach of confidentiality or feels uncomfortable, she or he may not want to admit having had sexual contact with a same-sex partner or any partner during a health-screening interview. It remains important for providers to anticipate reticence on the part of adolescents, given the epidemiological data available.
Given the level of sexual activity that adolescents in general participate in without proper education and sexual health awareness, there is, as stated earlier, a huge potential for adolescents to become part of the population with what the Centers for Disease Control and Prevention (CDC) terms “widespread” increases. Infections such as herpes, HPV, trichomoniasis and bacterial vaginosis are on the rise, as well as diseases such as chlamydia, especially in areas where screening and treatment are not readily available. STDs such as syphilis, hepatitis B, and chancroid are declining in incidence.
Although the demographics of the lifestyle and needs of LGBT adolescents remain constant in the United States, the provision of health and education services and resources for the LGBT youth population do not. Many communities provide little or nothing to affirm the psychological personhood of LGBT youth, thus passively contributing to depression and suicide. As well, the failure to screen for STDs and to educate this population on health and safer sex practices contributes to the spread of STDs. This is why the primary care provider has such a pivotal role in assisting these teens toward adulthood in a positive, responsible way of living and engaging in healthy, fulfilling, and responsible practices in relationships.
At this point, you can provide Cassandra with available literature, a demonstration of related products such as dental dams, and a gender-specific discussion on how people of alternative lifestyles practice safer sex.
What other areas are important to assess for LGBT youth?
When you have given time in the discussion for Cassandra to think about any other questions or issues she may have related to safe sex, you mention to her that the other part of having a healthy sex life is to be treated respectfully and to treat one’s partner respectfully as well. You let her know that, as her healthcare provider, it is important for you to know whether anyone has ever hurt her or tried to hurt her and how she responded to any incident like this. You tell her that many patients have mentioned this sort of thing and then listen carefully, because if she has ever been abused or disrespected in some way, it may take her time to be able to say it. You ask her if she has thought about hurting herself or hurt herself in the past, and if she is depressed or feeling hopeless or helpless. She clearly says no, so you can move on to the next point.
Depression, Suicide, and Violence
Depression and suicide are among the central health issues associated with gay adolescents. Gay male adolescents are two to three times more likely than their peers to attempt suicide (CDC, 2008). Primary factors in this trend include isolation, domestic abuse, and the lack of role models, which contribute to a profound sense of alienation that then exacerbates the difficulties associated with mainstream adolescence for both boys and girls.
In 1993, the American Academy of Pediatrics’ Committee on Adolescence reported that LGBT youth very often find themselves stigmatized and the recipients of others’ prejudice. They may find themselves in conflict with their families, communities, and schools. If parents react with anger, shock, or guilt upon learning that their child is gay or lesbian, the youth is left to seek understanding and acceptance by others outside of the home. Social and school environments may be even less supportive; gay and lesbian youth have been subject to name calling, ostracizing, or physical abuse. In the face of this rejection, the youth may become isolated, run away, become depressed, or commit suicide. Given such widespread social difficulty, it is particularly important for healthcare providers to offer a level of openness and acceptance to adolescents struggling with sexual identity. The American Academy of Pediatrics report advises healthcare providers that “. . . any youth struggling with sexual orientation issues should be offered appropriate referrals to providers and programs that can affirm the adolescent’s intrinsic worth regardless of sexual identity. Providers who are unable to be objective because of religious or other personal convictions should refer patients to those who can” (American Academy of Pediatrics, 1993).
Sexually Transmitted Diseases
You tell Cassandra that no matter what one’s orientation, it is important to be free of sexually transmitted diseases. You remind her that it is important for her and her partner to learn to be totally honest about any potential for disease (such as one of them having herpes, bisexuality, needle drug use, or multiple partners) before having sex. They should encourage each other to discuss which activities feel good and which ones do not.
You ask her if she has more questions right now. She does not, so you proceed to the physical exam. You also let her know that she does not need to take birth control unless she feels that it is something she needs, regardless of what her sisters have done in the past.
The Sexual History and Physical Examination
The practitioner is cautioned to obtain a sensitive and comprehensive history in order to define those areas that require a more extensive examination. Identifying high-risk behaviors or substance abuse will direct the practitioner’s focus during the exam.
The physical exam should include an evaluation of the sexual organs (women: breasts, external genitalia, vagina, cervix, uterus, and adnexa; men: penis, scrotum, rectum, and prostate), identifying the stage of puberty, and a thorough skin assessment (paying close attention to possible signs of abuse or trauma, and sexually transmitted diseases).
According to the American Cancer Society (2008), sexually active women should begin cervical cancer screening (Pap smears) about 3 years after they start having sexual relations. If she waits to have sex until she is over 18, she should start screening no later than age 21. Regardless of the young woman’s sexual orientation, she should have a regular Pap test yearly or the newer liquid-based Pap test every 2 years. Even though human papillomavirus (HPV) and the genital warts it can cause is very common in men, HPV-related cancers are very rare in men. There is currently no approved test for men.
Making the Diagnosis
Cassandra is moving through the steps necessary to manage a homosexual lifestyle. She seems comfortable with her sexual identity but is having difficulty communicating with her mother about her sexual orientation. She also needs healthcare education related to known health risk factors for lesbian youth.
Cassandra is not currently sexually active and is less than 18 years of age, so you don’t do a Pap smear. If she had been sexually active, it would have been appropriate to test for sexually transmitted diseases. These would have included chlamydia, gonorrhea, HSV-1, HSV-2, and trichomoniasis. After the exam, which was normal, you tell Cassandra that your impression is that she and her mother love each other and that this is a new stage in their relationship. This transition to being a woman and being responsible for herself will take openness and understanding from both sides. You ask her if she has someone she can confide in about her sexuality, or if she would like a referral for confidential counseling.
You let Cassandra know that this may be a difficult experience for her mother to understand and that Cassandra may have to be patient with her mother and realize that like many people in the world, her mother may not yet understand and accept that some people live different lifestyles. This lack of understanding could cause her mother to be afraid, to be in denial of the facts for a time, and perhaps to react negatively to Cassandra’s preferences. You ask Cassandra to consider that out of love, her mother is trying to assure that Cassandra has as much freedom to grow into womanhood as possible; she does not want a baby to interfere with those things right now, not realizing that Cassandra’s choices are different from her sisters. You explain that this transition to her mother’s acceptance will take time and honesty on Cassandra’s part and that this might also be facilitated by a referral with a mental health counselor where they could talk together about their experiences around this issue.
Cassandra tells you that she thinks she can talk with her mother about her sexuality without a counselor, but promises to come back if she is having difficulty or her mother seems to be too upset.
You encourage Cassandra to come back regularly for her yearly well-woman exams or if any issues arise that you may help with. Provide her with information regarding the HPV vaccine and encourage her to be vaccinated to help prevent cervical cancer and genital warts. At the end of the appointment you give her a handout of resources she can access for more information about sexual orientation and LGBT issues.
Key Points from the Case
1. Adolescents usually establish their sexual identity by the time they reach adolescence, even if they have not had an opportunity to act on it.
2. LGBT adolescents (and adults) may avoid medical care and appropriate health screenings because of a misperception that they are only necessary for heterosexuals.
3. Proper health screening and education is especially important in the primary care setting for LGBT teens because there may be nowhere else available in the community for proper screening and education to occur in an atmosphere of respect and trust.
Parents, Families and Friends of Lesbians and Gays (PFLAG):
Gay and Lesbian Medical Association (GLMA):
Indiana Youth Group (IYG):
Lesbian & Gay Child and Adolescent Psychiatric Association, resources:
The National Coalition for Gay, Lesbian, Bisexual, and Transgender Youth:
American Academy of Child and Adolescent Psychiatry. (1997). Gay and lesbian teens. Retrieved June 23, 2008, from http://www.puberty101.com/aacap_gayteens.shtml
American Academy of Pediatrics. (1993). Homosexuality and adolescence. Retrieved July 26, 2008, from http://www.medem.com/MedLB/article_detaillb_for_printer.cfm?article_ID=ZZZUHJP3KAC&sub_cat=269
American Academy of Pediatrics. (1999). Sexual stereotypes and sexual orientation. Retrieved June 23, 2008, from http://www.medem.com/search/article_display.cfm?path=\\TANQUERAY\M_ContentItem&mstr=/M_ContentItem/ZZZNZ1L6W7C.html&soc=AAP
American Academy of Pediatrics, Committee on Adolescence. (1993). Homosexuality and adolescence. Pediatrics, 92(4), 631–634.
American Cancer Society. (2008). Cervical cancer: Prevention and early detection. Retrieved October 6, 2008, from http://www.cancer.org/docroot/CRI/content/CRI_2_6x_cervical_cancer_
Centers for Disease Control and Prevention. (2007). CDC fact sheet: Genital HPV. Retrieved October 6, 2008, from http://www.cdc.gov/std/HPV/hpv-fact-sheet-press.pdf
Centers for Disease Control and Prevention. (2008). Lesbian, gay, bisexual and transgender health. Retrieved October 6, 2008, from http://www.cdc.gov/lgbthealth/
Kinsey Institute. (2005). Frequently asked sexuality questions to the Kinsey Institute. Retrieved October 5, 2008, from http://www.indiana.edu/~kinsey/resources/FAQ.html#homosexuality
U.S. Census Bureau. (2006). Arizona. S0902. Teenagers’ Characteristics. Retrieved April 21, 2009, from http://factfinder.census.gov/servlet/STTable?_bm=y&-qr_name=ACS_2006_EST_G00_S0902&-geo_id=04000US04&-ds_name=ACS_2006_EST_G00_&-_lang=en