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AMERICAN ACADEMY OF PEDIATRICS

CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Barbara L. Frankowski, MD, MPH; and the Committee on

Sexual Orientation and Adolescents

ABSTRACT. The American Academy of Pediatrics is- tional, and social health, primarily because of societal sued its first statement on and adoles- stigma, which can result in isolation.1,2 Because self- cents in 1983, with a revision in 1993. This report reflects awareness of commonly occurs the growing understanding of youth of differing sexual during adolescence, the pediatrician should be avail- orientations. Young people are recognizing their sexual able to youth who are struggling with sexual orien- orientation earlier than in the past, making this a topic of tation issues and support a healthy passage through importance to pediatricians. Pediatricians should be aware that some youths in their care may have concerns the special challenges of the adolescent years. Pedi- about their sexual orientation or that of siblings, friends, atricians may be called on to help parents, siblings, parents, relatives, or others. Health care professionals and extended families of nonheterosexual youth. should provide factual, current, nonjudgmental informa- Also, nonheterosexual youth and adults are part of tion in a confidential manner. All youths, including peer groups with whom all pediatric patients and those who know or wonder whether they are not hetero- their parents spend time in the neighborhood, at sexual, may seek information from physicians about - school, or at work. Thus, pediatricians may be called ual orientation, sexually transmitted diseases, substance on to help promote better understanding of issues , or various psychosocial difficulties. The pediatri- involving nonheterosexual youth. cian should be attentive to various potential psychosocial , , and bisexual people in the United difficulties, offer counseling or refer for counseling when necessary and ensure that every sexually active States have unique health risks. The US Department youth receives a thorough medical , physical ex- of Health and Services has identified 29 amination, immunizations, appropriate laboratory tests, Healthy People 2010 objectives in which disparities and counseling about sexually transmitted diseases (in- exist between homosexual or bisexual persons and cluding human immunodeficiency virus infection) and heterosexual persons. These focus areas include ac- appropriate treatment if necessary. cess to care, educational and community-based pro- Not all pediatricians may feel able to provide the type grams, , immunization and infec- of care described in this report. Any pediatrician who is tious disease, sexually transmitted diseases (STDs) unable to care for and counsel nonheterosexual youth including human immunodeficiency virus (HIV) in- should refer these patients to an appropriate colleague. fection, injury and violence prevention, mental Pediatrics 2004;113:1827–1832; sexual orientation, adoles- cents, homosexuality, gay, lesbian, bisexual. health and mental disorders, substance abuse, and tobacco use.3

ABBREVIATIONS. STD, sexually transmitted disease; HIV, hu- DEFINITIONS immunodeficiency virus; AAP, American Academy of Pedi- atrics; AIDS, acquired immunodeficiency syndrome. Sexual orientation4,5 refers to an individual’s pat- tern of physical and emotional arousal toward other INTRODUCTION persons. Heterosexual individuals are attracted to ediatricians are being asked with increasing persons of the opposite sex, homosexual individuals frequency to address questions about sexual are attracted to persons of the same sex, and bisexual Pbehavior and sexual orientation. It is important individuals are attracted to persons of both . that pediatricians be able to discuss the range of Homosexual males are often referred to as “gay”; sexual orientation with all adolescents and be com- homosexual are often referred to as “les- petent in dealing with the needs of patients who are bian.” In contrast, identity is the knowledge gay, lesbian, bisexual, or transgendered or who may of oneself as being male or , and is not identify themselves as such but who are experi- the outward expression of maleness or femaleness. encing confusion with regard to their sexual orienta- and gender role usually conform to tion. Young people whose sexual orientation is not anatomic sex in both heterosexual and homosexual heterosexual can have risks to their physical, emo- individuals. Exceptions to this are transgendered in- dividuals and transvestites. Transgendered individ- uals feel themselves to be of a gender different from The guidance in this report does not indicate an exclusive course of treat- their biological sex; their gender identity does not ment or serve as a standard of medical care. Variations, taking into account match their anatomic or chromosomal sex. Transves- individual circumstances, may be appropriate. PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- tites are individuals who dress in the clothing of the emy of Pediatrics. opposite gender and derive pleasure from such ac-

Downloaded from www.aappublications.org/news by guestPEDIATRICS on September 30, Vol. 2021 113 No. 6 June 2004 1827 tions; their gender role does not match societal ence sexual orientation.4,5 Current knowledge sug- norms. Transgendered individuals and transvestites gests that sexual orientation is usually established can be heterosexual, homosexual, or bisexual. during early childhood.1,2,4,5 Sexual orientation is not synonymous with sexual The estimated proportion of Americans who are activity or sexual behavior (the way one chooses to homosexual is imprecise at best, because surveys are express one’s sexual feelings). Certain sexual behav- hampered by the stigmatization and the climate of iors can put individuals of any sexual orientation at that still surround homosexuality. Past studies risk of (penile-vaginal ) asked more often about sexual behavior and not and/or certain diseases (penile-vaginal, oral, and sexual orientation. Kinsey et al,9,13 from their studies anal sexual intercourse). Especially during adoles- in the 1930s and 1940s, reported that 37% of adult cence, individuals may participate in a variety of men and 13% of adult women had at least 1 sexual sexual behaviors. Many homosexual adults report experience resulting in with a person of the having relationships and sexual activity with per- same sex and that 4% of adult men and 2% of adult sons of the opposite sex as adolescents,6,7 and many women are exclusively homosexual in their behavior adults who identify themselves as heterosexual re- and fantasies. A more recent review of various US port sexual activity with persons of the same sex studies estimated that 2% of men are exclusively during adolescence.8–10 Also, many youth label homosexual and 3% are bisexual.14 Other current themselves as gay, lesbian, or bisexual years after studies conclude that somewhere between 3% and labeling their attractions as such.11 In addition, ado- 10% of the adult population is gay or lesbian, and lescents may also self-identify as nonheterosexual perhaps a larger percentage is bisexual.4,5 Sorenson15 without ever being sexually active. Pediatricians surveyed a group of 16- to 19-year-olds and reported need to understand that they should inquire about that 6% of females and 17% of males had at least 1 or orientation even when youth do sexual experience with a person of the same sex. not report being gay or lesbian. Remafedi et al,10 in a large, population-based study of junior and senior high school students performed ETIOLOGY AND PREVALENCE in the late 1980s that measured , emo- Homosexuality has existed in most societies for as tional attraction, and sexual behavior, found that long as recorded descriptions of sexual beliefs and more than 25% of 12-year-old students felt uncertain practices have been available.4 Societal attitudes to- about their sexual orientation. This uncertainty de- ward homosexuality have had a decisive effect on creased with the passage of time and increasing sex- the extent to which individuals have hidden or made ual experience to only 5% of 18-year-old students. known their sexual orientation. Only 1.1% of students reported themselves as pre- Human sexual orientation most likely exists as a dominantly homosexual or bisexual. However, 4.5% continuum from solely heterosexual to solely homo- reported primary sexual attractions to persons of the sexual. In 1973, the American Psychiatric Association same sex, which better reflects actual sexual orienta- reclassified homosexuality as a sexual orientation or tion. The Garofalo et al study,16 based on the 1995 expression and not a mental disorder.12 The mecha- Massachusetts Youth Risk Behavior Survey, found nisms for the development of a particular sexual that 2.5% of youth self-identified as gay, lesbian, or orientation remain unclear, but the current literature bisexual. and most scholars in the field state that one’s sexual These data illustrate the complexity of labeling orientation is not a choice; that is, individuals do not sexual orientation in adolescents. Health care profes- choose to be homosexual or heterosexual.8,11 sionals should be aware that a large number of ad- A variety of theories about the influences on sex- olescents have questions about their sexual feelings; ual orientation have been proposed.5 Sexual orienta- some are attracted to and may have sexual relations tion probably is not determined by any one factor but with people of the same sex, and a small number by a combination of genetic, hormonal, and environ- may know themselves to be gay or lesbian. mental influences.2 In recent decades, biologically based theories have been favored by experts. The SPECIAL NEEDS OF NONHETEROSEXUAL AND high concordance of homosexuality among monozy- QUESTIONING YOUTH gotic twins and the clustering of homosexuality in The overall goal in caring for youth who are or family pedigrees support biological models. There is think they might be gay, lesbian, or bisexual is the some evidence that prenatal exposure in- same as for all youth: to promote normal adolescent fluences development of sexual orientation, but post- development, social and emotional well-being, and natal sex steroid concentrations do not vary with physical health. If their environment is critical of sexual orientation. The reported association in males their emerging sexual orientation, these adolescents between homosexual orientation and loci on the X may experience profound isolation and fear of dis- chromosome remains to be replicated. Some research covery, which interferes with achieving develop- has shown neuroanatomic differences between ho- mental tasks of adolescence related to self-esteem, mosexual and heterosexual persons in sexually di- identity, and intimacy.17,18 Nonheterosexual youth morphic regions of the brain.5 Although there con- often are subjected to harassment and violence; 45% tinues to be controversy and uncertainty as to the of and 20% of surveyed were vic- genesis of the variety of human sexual orientations, tims of verbal and physical assaults in secondary there is no scientific evidence that abnormal parent- school specifically because of their sexual orienta- ing, , or other adverse life events influ- tion.1,19

1828 SEXUAL ORIENTATIONDownloaded AND from ADOLESCENTSwww.aappublications.org/news by guest on September 30, 2021 Nonheterosexual youth are at higher risk of drop- there is a range of sexual orientation. The portrayal ping out of school, being kicked out of their homes, of openly gay or lesbian characters in media is start- and turning to life on the streets for survival. Some of ing to change how adolescents view these differ- these youth engage in substance use, and they are ences. Even adolescents who are quite sure of their more likely than heterosexual peers to start using own are likely to have friends, rela- tobacco, alcohol, and illegal drugs at an earlier age.20 tives, teachers, etc whom they know or suspect to be Nonheterosexual youth are more likely to have had gay or lesbian or who are struggling with questions sexual intercourse, to have had more partners, and to about their sexual orientation. Rather than asking have experienced sexual intercourse against their patients whether they have a “boyfriend” or “girl- will,20 putting them at increased risk of STDs includ- friend,” pediatricians could ask, “Have you ever had ing HIV infection. In a recent study of HIV sero- a romantic relationship with a boy or a girl?” or prevalence, 7% of 3492 15- to 22-year-old males who “When you think of people to whom you are sexu- have sex with males living in 7 US cities were HIV- ally attracted, are they men, women, both, neither, or seropositive. Among adolescent males who have sex are you not sure yet?” By doing so, pediatricians with males, HIV seroprevalence rates in descending open the door to additional communication and start order were highest among black adolescents, then to break down and stigmatization. It im- “mixed race or other” adolescents, and then Hispanic plies that any of the options is possible and that an adolescents and were lowest among Asian and white adolescent may not be sure of his or her sexual adolescents.21 Women having sex with women have orientation. If these issues are addressed, specifically the lowest risk of any STD, but lesbian adolescents targeted medical screening, medical treatment, and remain at significant risk because they are likely to anticipatory guidance can be provided to adolescents have had sexual intercourse with males. Youth in who need it. Pediatricians can have an important high school who identify themselves as gay, lesbian, positive effect on young people and their families by or bisexual; engage in sexual activity with persons of addressing sexual orientation and sexual behavior the same sex; or report same-sex romantic attractions on several levels: office and hospital policies, clinical or relationships are more likely to attempt suicide, be care, and community advocacy.2 victimized, and abuse substances.20,22 Although only representing a portion of youth who someday will OFFICE PRACTICE: ENSURE A SAFE AND self-identify as gay, lesbian, or bisexual, school-based SUPPORTIVE ENVIRONMENT studies have found that these adolescents, compared A pediatric encounter may give adolescents a rare with heterosexual peers, are 2 to 7 times more likely opportunity to discuss their concerns about their to attempt suicide,16,19,23,24 are 2 to 4 times more sexual orientation and/or activities. Adolescents’ likely to be threatened with a weapon at school,16,23 level of comfort in the pediatric office sets the tone and are more likely to engage in frequent and heavy for their other health care interactions. The way sex- use of alcohol, marijuana, and cocaine. It is important uality and other important personal issues are dis- to note that these psychosocial problems and suicide cussed also sets an example for all adolescents and attempts in nonheterosexual youth are neither uni- their parents. In the office, pediatricians are encour- versal nor attributable to homosexuality per se, but aged to28: they are significantly associated with stigmatization of gender nonconformity, stress, violence, lack of 1. Assure the patient that his or her confidentiality is support, dropping out of school, family problems, protected.29 acquaintances’ suicide attempts, , and 2. Implement policies against insensitive or inappro- substance abuse.2,25 In addition to suicidality, young priate jokes and remarks by office staff. gay and bisexual men might also suffer body image 3. Be sure that information forms use gender-neu- dissatisfaction and disordered eating behaviors for tral, nonjudgmental language. some of the same reasons.26 4. Consider displaying posters, brochures, and infor- Nonheterosexual youth are represented within all mation on bulletin boards that demonstrate sup- populations of adolescents, all social classes, and all port of issues important to nonheterosexual youth racial and ethnic groups. Ethnic minority youth who and their families (eg, the American Academy of are nonheterosexual are required to manage more Pediatrics [AAP] brochure “Gay, Lesbian, and Bi- than one stigmatized identity, which increases their sexual Teens: Facts for Teens and their Parents”). level of vulnerability and stress.27 They retain their 5. Provide information about support groups and minority status when they seek help in the predom- other resources to nonheterosexual youth and inately white gay and lesbian support communities. their friends and families if requested. In addition, youth are represented among handicapped adolescents, homeless adoles- COMPREHENSIVE HEALTH CARE FOR ALL cents, and incarcerated youth.1 ADOLESCENTS Most nonheterosexual youths are “invisible” and Pediatricians are not responsible for labeling or will pass through pediatricians’ offices without rais- even identifying nonheterosexual youth. Instead, the ing the issue of sexual orientation on their own. pediatrician should create a clinical environment in Therefore, health care professionals should raise is- which clear messages are given that sensitive per- sues of sexual orientation and sexual behavior with sonal issues including sexual orientation can be dis- all adolescent patients or refer them to a colleague cussed whenever the adolescent feels ready to do so. who can. Such discussions normalize the notion that A major obstacle to effective medical care is adoles-

Downloaded from www.aappublications.org/news byAMERICAN guest on September ACADEMY 30, 2021 OF PEDIATRICS 1829 cents’ misunderstanding of their right to confidential 1. Be prepared to refer adolescents’ care if you have care.30 The pediatrician should be ready to raise and personal barriers to providing such care. Many discuss issues of sexual orientation with all adoles- individuals have strong negative attitudes about cents, particularly those in distress or engaged in homosexuality or may simply feel uncomfortable high-risk behaviors. The pediatrician should be able with the subject. Even discomfort expressed to explore the adolescent’s understanding and con- through body language can send a very damaging cerns about sexual orientation, dispel any miscon- message to nonheterosexual youth. It is an ethical ceptions, provide appropriate medical care and an- and professional obligation to make an appropri- ticipatory guidance, and connect the adolescent to ate referral in these situations for the good of the appropriate supportive community resources. Pedi- child or adolescent. 29,31 atricians are encouraged to : 2. Assure the patient that his or her confidentiality is 1. Be aware of the special issues surrounding the 29 29 protected. Discuss with adolescents and, if ap- development of sexual orientation. propriate, their parents whether they wish to have 2. Assure the patient that his or her confidentiality is 29 their sexual orientation recorded in office and hos- protected. pital charts. Many nonheterosexual adults prefer 3. Discuss emerging sexuality with all adolescents.32 to have this information recorded so that health • Be knowledgeable that many heterosexual care professionals will not assume heterosexual- youth also may have sexual experiences with ity. people of their own sex. Labeling as homosexual an adolescent who has had sexual experiences 3. Help the adolescent think through his or her feel- with persons of the same sex or is questioning ings carefully; strong same-sex feelings and even his or her sexual orientation could be premature, sexual experiences can occur at this age and do inappropriate, and counterproductive. not define sexual orientation. • Use gender-neutral language in discussing sex- 4. Carefully identify all risky behaviors (sexual be- uality; use the word “partner” rather than “boy- haviors; use of tobacco, alcohol, and drugs; etc) friend” or “girlfriend,” and talk about “protec- and offer advice and treatment if indicated. tion” rather than just “.” 5. Ask about mental health concerns and evaluate or • Give evidence of support and acceptance to ad- refer patients with identified problems. olescents questioning their sexual orientation. 6. Offer support and advice to adolescents faced • Provide information and resources regarding with or anticipating conflicts with families and/or gay, lesbian, and bisexual issues to all interested friends. adolescents. 7. Encourage transition to adult health care when • Ask all adolescents about risky behaviors, de- age-appropriate. pression, and suicidal thoughts. Pediatricians should be aware that the revelation • Encourage , discourage multiple part- ners, and provide “safer sex” guidelines to all of an adolescent’s homosexuality (also called disclo- adolescents.33 Discuss the risks associated with sure or “”) has the potential for intense 1,2,28 anal intercourse for those who choose to engage family discord. In many families, it precipitates in this behavior, and teach them ways to de- physical and/or emotional abuse or even expulsion. crease risk. The pediatrician can advise the adolescent to use • Counsel all adolescents about the link between certain language that may be helpful at the time of substance use (alcohol, marijuana, and other disclosure, such as “I am the same person, you just drugs) and unsafe sexual intercourse. know one more thing about me now.” However, • Ask all adolescents about personal experience there is no one disclosure technique that will pre- with violence including sexual or intimate-part- clude negative reactions. Parents, siblings, and other ner violence. family members may require professional help to Provide additional screening and education as in- deal with their confusion, anger, guilt, and feelings dicated for each adolescent’s sexual activity: of loss, and professionals who work with adolescents • STD testing from appropriate sites34 may be required to intervene on the adolescent’s • HIV testing with appropriate support and coun- behalf. If the pediatrician has a relationship with the seling35 parents from ongoing primary care, he or she can be • Pregnancy testing and counseling36,37 an important initial source of support and informa- • Papanicolaou testing tion. However, adolescents should be counseled to • Hepatitis B and, when appropriate, hepatitis A think carefully about the consequences of disclosure immunization and to take their time in sharing information that 4. Ensure that colleagues to whom adolescents are could have many repercussions.1 referred or with whom you consult are respectful With regard to parents of nonheterosexual adoles- of the range of adolescents’ sexual orientation. cents, pediatricians are encouraged to: SPECIAL CONSIDERATIONS FOR 1. Advise adolescents about whether, when, and NONHETEROSEXUAL YOUTH how to disclose their nonheterosexuality to their For adolescents who self-identify as gay, lesbian, parents. If unsure, assist the adolescent in finding or bisexual, pediatricians should be particularly a knowledgeable professional who can help. aware of several points: 2. Be knowledgeable about the process of disclosure.

1830 SEXUAL ORIENTATIONDownloaded AND from ADOLESCENTSwww.aappublications.org/news by guest on September 30, 2021 3. Be supportive of parents of adolescents who have creased prevalence of adolescent suicidal behavior disclosed that they are not heterosexual. Most underscore the critical need to address and seek to states have chapters of Parents and Friends of prevent the major physical and mental health prob- Lesbians and Gays (PFLAG) to which interested lems that confront nonheterosexual youths in their families may be referred. transition to a healthy adulthood. 4. Remind parents and adolescents that gay and les- bian individuals can be successful parents them- Committee on Adolescence, 2002–2003 selves.38–41 David W. Kaplan, MD, MPH, Chairperson 5. Be prepared to refer parents if you do not feel Angela Diaz, MD Ronald A. Feinstein, MD personally comfortable accepting this responsibility. Martin M. Fisher, MD Jonathan D. Klein, MD, MPH COMMUNITY ADVOCACY W. Samuel Yancy, MD Despite AAP statements issued in 198342 and 199343 urging excellent clinical care for nonhetero- Past Committee Members sexual adolescents, these patients still experience Luis F. Olmedo, MD many risks to their physical and mental health and Ellen S. Rome, MD, MPH safety that occur outside the scope of usual office practice. Some pediatricians may wish to take a Liaisons S. Paige Hertweck, MD broader role in their communities to help decrease American College of Obstetricians and these risks. Pediatricians could model and provide Gynecologists opportunities for increasing awareness and knowl- Glen Pearson, MD edge of homosexuality and among school American Academy of Child and Adolescent staff, mental health professionals, and other commu- Psychiatry nity leaders. They can make themselves available as Miriam E. Kaufman, MD resources for community HIV and acquired immu- Canadian Paediatric Society nodeficiency syndrome (AIDS) education and pre- Barbara L. Frankowski, MD, MPH vention activities. It is critical that schools find a way Past Liaison to Section on School Health to create safe and supportive environments for stu- Diane G. Sacks, MD dents who are or wonder about being nonhetero- Past Liaison From Canadian Paediatric Society sexual or who have a parent or other family member who is nonheterosexual. Support from respected pe- Consultant diatricians can facilitate these efforts greatly. Pedia- Ellen C. Perrin, MD tricians who choose to be active on these issues may wish to2,28: Staff Karen S. Smith 1. Help raise awareness among school and commu- nity leaders of issues relevant to nonheterosexual REFERENCES youth. 1. Ryan C, Futterman D. Lesbian and Gay Youth: Care and Counseling. New 2. Help with the discussion of when and how factual York, NY: Columbia University Press; 1998 materials about sexual orientation should be in- 2. Perrin EC. Sexual Orientation in Child and Adolescent Health Care. 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1832 SEXUAL ORIENTATIONDownloaded AND from ADOLESCENTSwww.aappublications.org/news by guest on September 30, 2021 Sexual Orientation and Adolescents Barbara L. Frankowski Pediatrics 2004;113;1827 DOI: 10.1542/peds.113.6.1827

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/113/6/1827 References This article cites 31 articles, 15 of which you can access for free at: http://pediatrics.aappublications.org/content/113/6/1827#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Developmental/Behavioral Pediatrics http://www.aappublications.org/cgi/collection/development:behavior al_issues_sub Psychosocial Issues http://www.aappublications.org/cgi/collection/psychosocial_issues_s ub Adolescent Health/Medicine http://www.aappublications.org/cgi/collection/adolescent_health:med icine_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 30, 2021 Sexual Orientation and Adolescents Barbara L. Frankowski Pediatrics 2004;113;1827 DOI: 10.1542/peds.113.6.1827

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