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Recommendations for Promoting the Health and Well-Being of Lesbian, Gay, Bisexual, and Transgender Adolescents: A Position Paper of the Society for Adolescent Health and Medicine

  • Society for Adolescent Health and Medicine

      Abstract

      Adolescent health care providers frequently care for patients who identify as lesbian, gay, bisexual, or transgendered (LGBT), or who may be struggling with or questioning their sexual orientation or gender identity. Whereas these youth have the same health concerns as their non-LGBT peers, LGBT teens may face additional challenges because of the complexity of the coming-out process, as well as societal discrimination and bias against sexual and gender minorities. The Society for Adolescent Health and Medicine encourages adolescent providers and researchers to incorporate the impact of these developmental processes (and understand the impacts of concurrent potential discrimination) when caring for LGBT adolescents. The Society for Adolescent Health and Medicine also encourages providers to help positively influence policy related to LGBT adolescents in schools, the foster care system, and the juvenile justice system, and within the family structure. Consistent with other medical organizations, the Society for Adolescent Health and Medicine rejects the mistaken notion that LGBT orientations are mental disorders, and opposes the use of any type of reparative therapy for LGBT adolescents.

      Positions

      The Society for Adolescent Health and Medicine supports the following positions:
      • All health care providers who care for adolescents should be trained to provide competent and nonjudgmental care for lesbian, gay, bisexual, or transgendered (LGBT) youth. Competency in this area should include an understanding of adolescent sexuality development, the ability to identify mental health issues related to either the coming-out process or victimization, and familiarity with physical and sexual health issues related to sexual orientation or gender identity.
      • Health care providers should understand that the majority of LGBT young people are healthy and well-adjusted teenagers and young adults. The high-risk behaviors exhibited by some LGBT teens more often reflect reactions to social stigma and non-acceptance by peers and society.
      • Sexual orientation and gender identity are dynamic constructs. Health care providers, educators, policy makers, and researchers should be cautious in assigning labels to an adolescent's sexual orientation, because this may evolve over time. Providers should ask adolescents how they self-identify, and should be guided by the youth's language and self-concept.
      • Family connectedness and support are important protective factors against depression, drug use, and high-risk sexual behavior in LGBT adolescents. However, practitioners also should understand that not all LGBT adolescents may be ready to disclose their sexuality to their family. When LGBT teens decide to disclose their sexuality or gender identity, providers should aim to assist families with acceptance of their LGBT teenagers.
      • Lesbian, gay, bisexual, or transgendered youth may be at increased risk of bullying and victimization by peers and adults, including teachers, coaches, and family members; and victimization is associated with an increased risk for depression and suicide. Health care providers should be comfortable discussing these issues with their LGBT patients and should take an active role in educating the schools and community on prevention efforts to prevent and stop victimization. The Society for Adolescent Health and Medicine believes that sexual minority adolescents should have full and appropriate legal protection from victimization under both local and federal laws.
      • Because victimized LGBT youth are at increased risk of depression and suicidality, providers should screen for these mental health issues and intervene as appropriate.
      • Antidiscrimination policies should be implemented to protect LGBT youth in foster care settings. Municipalities should disseminate policy guidelines to ensure appropriate care for LGBT youth in out-of-home venues.
      • Lesbian, gay, bisexual, or transgendered youth in juvenile detention settings are at risk of harassment and bullying from fellow detainees as well as staff. Local juvenile justice systems should adopt policies to ensure the physical and mental well-being of incarcerated youth.
      • For youth who are struggling with sexual orientation or gender identity, affirmative therapeutic approaches can help adolescents explore their identities in a healthy manner. Reparative “therapy,” which attempts to change one's sexual orientation or gender identity, is inherently coercive and inconsistent with current standards of medical care.
      • Adolescent health care providers should be educated regarding the health care needs of sexually active LGBT teenagers. Guidance for screening individuals who are sexually active with members of the same sex is described in the Center for Disease Control's Sexually Transmitted Disease Treatment Guidelines 2010 [
        • Centers for Disease Control and Prevention
        Sexually Transmitted Diseases Guidelines, 2010.
        ].
      • Future research on all of these aspects of LGBT health is needed to direct provider interventions, education, and community policy.

      Background

      Given wider access to information and more positive media images, anecdotal data suggest that LGBT adolescents are coming out at younger ages than previous generations of LGBT adults. As a result, providers are more likely to serve LGBT adolescents in a wide range of settings. This offers many opportunities to identify LGBT youth at risk and to provide appropriate services and foster positive development.
      Sexual orientation includes multidimensional constructs involving three primary dimensions: sexual attraction, behavior, and identity (i.e., heterosexual, bisexual, lesbian/gay) [
      • Institute of Medicine
      The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding.
      ]. Each dimension may exist on a wide spectrum [
      • Austin S.B.
      • Conron K.J.
      • Patel A.
      • Freedner N.
      Making sense of sexual orientation measures: Findings from a cognitive processing study with adolescents on health survey questions.
      ,
      • Saewyc E.M.
      • Bauer G.R.
      • Skay C.L.
      • et al.
      Measuring sexual orientation in adolescent health surveys: Evaluation of eight school-based surveys.
      ] and a person's experience of each dimension may evolve throughout adolescence and adulthood [
      • Savin-Williams R.C.
      • Ream G.L.
      Prevalence and stability of sexual orientation components during adolescence and young adulthood.
      ]. Thus in adolescence, sexual orientation and gender identity should be viewed as a multifaceted and dynamic part of one's persona. Researchers, clinicians and policy makers should consider these multiple dimensions of sexual orientation when interacting with all adolescents, to provide the highest level of care in these settings.

      Methods

      The stated positions result from a review of the scientific literature as well as expert consensus from specialists involved in research, teaching, and providing care to LGBT adolescents.

      Statement of problem/information

      Families and LGBT youth

      Family connectedness is essential for healthy development of adolescents in general, and it has also been shown to be an important correlate of health outcomes among lesbian, gay, and bisexual youth [
      • Needham B.L.
      • Austin E.L.
      Sexual orientation, parental support and health during the transition to young adulthood.
      ]. Although parents may react negatively to their child's disclosure of a non-heterosexual orientation, research also shows that many family relationships improve after parents become sensitized to their children's needs and well-being [
      • D'Augelli A.R.
      • Grossman A.H.
      • Starks M.T.
      Parent's awareness of lesbian, gay, and bisexual youth's sexual orientation.
      ].
      Research from the Family Acceptance Project has found that specific parental and care giver reactions to an adolescent's LGBT identity have a compelling impact on their LGBT children's health, mental health, and well-being [
      • Ryan C.
      Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children.
      ]. Those who report high levels of family rejection during adolescence were 8.4 times more likely to report having attempted suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to report having engaged in unprotected sexual intercourse, compared with peers from families that report no or low levels of family rejection [
      • Ryan C.
      • Huebner D.
      • Diaz R.M.
      • Sanchez J.
      Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay and bisexual young adults.
      ].
      Conversely, LGBT youth who report family acceptance during adolescence show better general health and well-being than peers who were not accepted by their families [
      • Ryan C.
      • Russell S.
      • Huebner D.
      • et al.
      Family acceptance in adolescents and the health of LGBT young adults.
      ]. Specifically, this research shows that family acceptance is associated with higher levels of self-esteem, social support, and general health, and is protective against depression, substance abuse, and suicidal ideation and suicide attempts in young adulthood. Providers may help to facilitate disclosure by youth to their families, and should emphasize the importance of providing support to their children.
      Lesbian, gay, bisexual, or transgendered victimization. Lesbian, gay, bisexual, or transgendered youth frequently experience bullying and violence based on their actual or perceived sexual orientation and gender expression. Although most data focus on victimization at school, LGBT youth may be victimized in other social settings, such as online [
      • Pilkington N.W.
      • D'Augelli A.R.
      Victimization of lesbian, gay, and bisexual youth in community settings.
      ]. In a recent national community survey of middle and high school LGBT students, more than 85% of responders reported that they had been victims of verbal harassment, 40% experienced physical harassment, and 19% had been physically assaulted at school in the previous year [
      • Kosciw J.G.
      • Greytak E.A.
      • Diaz E.M.
      • et al.
      The 2009 National School Climate Survey: The experiences of lesbian, gay, bisexual and transgender youth in our nation's schools.
      ]. In the same survey, nearly two thirds reported feeling unsafe in school because of their sexual orientation.
      Victimization at school is common among LGBT students [
      • Bontempo D.E.
      • D'Augelli A.R.
      Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths' health risk behavior.
      ,
      • Garofalo R.
      • Wolf R.C.
      • Kessel S.
      • et al.
      The association between health risk behaviors and sexual orientation among a school-based sample of adolescents.
      ,
      • Berlan E.D.
      • Corliss H.L.
      • Field A.E.
      Sexual orientation and bullying among adolescents in the Growing Up Today Study.
      ]. For example, the 2009 New York City Youth Risk Behavior Survey reported that students who identified as LGBT were twice as likely to be bullied online or electronically (cyber-bullied) than heterosexual students.
      Bullying can range from verbal harassment to physical violence or even sexual abuse. Lesbian, gay, bisexual, or transgendered victims of bias-related violence may fear additional victimization if the cause of the attack is revealed; as a result, they may not disclose the attack or its cause. In these instances, this denial may prevent them from getting adequate external support needed to recover from the attack. Reactions to victimization may include post-traumatic stress disorder, sleep disturbances, anxiety, depression, nightmares, somatization, and illegal drug use as well as suicide attempts [
      • Pilkington N.W.
      • D'Augelli A.R.
      Victimization of lesbian, gay, and bisexual youth in community settings.
      ].
      Victimization independently correlates with past suicide attempts [
      • Hershberger S.L.
      • Pilkington N.W.
      • D'Augelli A.R.
      Predictors of suicide attempts among gay, lesbian, and bisexual youth.
      ] as well as sexual risk behaviors and substance use. Data from the National Longitudinal Study of Adolescent Health specifically suggest that the association between sexual orientation and suicidality is mediated by victimization, among other suicidal risk factors. Furthermore, the association between victimization and depression/suicide risk is attenuated by family support and self-acceptance [
      • Russell S.T.
      • Joyner K.
      Adolescent sexual orientation and suicide risk: Data from a national Study.
      ].
      The Gay, Lesbian, and Straight Education Network's 2005 online survey revealed that having a school harassment policy specific to sexual orientation or gender identity/expression is associated with increased perception of student safety and decreased harassment at school. However, 10% of students reported not mentioning harassment to school staff because they believed that the teachers were powerless to improve the situation. This suggests a notable gap between observed incidents and those that are reported by students [
      • Harris Interactive and Gay, Lesbian and Straight Education Network
      From teasing to torment: School climate in America, a survey of students and teachers.
      ].
      Although little is documented about youths' disclosure of anti-LGBT bullying in the clinical setting, experience suggests that health care providers should screen youth for homophobic victimization and associated effects. Health care providers should educate schools about the adverse health effects of bullying and victimization, the importance of intervening to stop harassment when observed, and the importance of encouraging youth to report incidents. In addition, health care providers should continue to advocate for both local and national anti-bullying policy and legislation that includes anti-LGBT bullying.

      Lesbian, gay, bisexual, or transgendered youth in foster care settings

      According to child welfare professionals, LGBT youth are disproportionately represented in foster care, although the exact number is unknown [
      • Wilber S.
      • Ryan C.
      • Marksamer J.
      CWLA Best Practice Guidelines: Serving LGBT youth in out-of-home care.
      ]. Lesbian, gay, bisexual, or transgendered youth enter foster care for various reasons, but many enter either directly or indirectly because of conflict, mistreatment, or neglect related to their sexual orientation or gender identity. These youth may report harassment by other children and staff in group and foster homes, especially when placed with care givers who are poorly prepared to deal with their sexual orientation or gender identity.
      Legislation such as the United States' Adoption and Safe Families Act of 1997 emphasizes permanency (e.g., placement of youth in stable and loving homes), safety, and well-being for youth in the foster care system. Until more recently, however, attention on improving services for LGBT youth in custodial care has been limited, resulting in uneven practices across jurisdictions, inappropriate and discriminatory care, little attention to permanency, and unstable home placements for these teens. One United States study reported that the average time in each foster care setting for a sample of LGBT youth was two to three times shorter then the federal government's suggested placement duration [
      • Mallon G.P.
      • Aledort N.
      • Ferrera M.
      There's no place like home: Achieving safety, permanency, and well-being for lesbian and gay adolescents in out-of-home care settings.
      ]. Lesbian, gay, bisexual, or transgendered youth may also run away from foster homes and shelters, adding to the disproportionate numbers of homeless LGBT youth. These homeless youth report greater victimization, alcohol abuse, survival sex, and suicidal ideation than their non-LGBT homeless peers [
      • Leeuwen J.M.
      • Boyle S.
      • Salomonsen-Sautel S.
      • et al.
      Lesbian, gay, and bisexual homeless youth: An eight-city public health perspective.
      ].
      In 2006, the Child Welfare League of America published the Best Practice Guidelines for LGBT Adolescents in Out-of-Home Care [
      • Wilber S.
      • Ryan C.
      • Marksamer J.
      CWLA Best Practice Guidelines: Serving LGBT youth in out-of-home care.
      ]. These practices cover a range of issues, including positive youth development, development and expression of sexual orientation and gender identity, positive social and recreational outlets, and prohibiting practices that pathologize and discriminate against LGBT youth. These guidelines can be applied in any country that provides foster care services for youth.
      Providers can help families, care givers, and foster parents understand the need to reduce rejecting behaviors that put LGBT youth and risk and increase supportive behaviors that promote well-being. Permanency should be an important priority for LGBT youth, as with non-LGBT youth.

      Lesbian, gay, bisexual, or transgendered youth in juvenile justice facilities

      There is limited research on LGBT youth in the juvenile justice system, but LGBT youth are also reported to be disproportionately overrepresented in juvenile detention and probation facilities, and policies have been developed to guide their placement and care [
      • Wilber S.
      • Ryan C.
      • Marksamer J.
      CWLA Best Practice Guidelines: Serving LGBT youth in out-of-home care.
      ]. The following outlines, issues, and recommendations address the unique issues related to this population.
      Lesbian, gay, bisexual, or transgendered youth who enter detention and correctional settings frequently face challenges stemming from overt hostility of other youths and/or institutional staff. Youth with gender variant behaviors are at highest risk for bullying. Because LGBT youth tend to be viewed negatively by juvenile courts and juvenile corrections staff, their concerns may place them at risk for physical isolation or their concerns may be ignored [
      • Wilber S.
      • Ryan C.
      • Marksamer J.
      CWLA Best Practice Guidelines: Serving LGBT youth in out-of-home care.
      ].
      Transgender youth present a complex set of concerns within residential, detention, and correctional settings, especially with regard to housing. Transgender youth housed with peers of the same birth gender may be more likely to be assaulted by their peers, whereas staff may have concerns about sexual activity when transgender youth are housed with youth of the opposite birth gender. Institutional care guidelines published by legal experts on transgender youth can help facilities respond appropriately [
      • Majd K.
      • Marksamer J.
      • Reyes C.
      Hidden injustice: Lesbian, gay, bisexual and transgender youth in juvenile courts.
      ].
      Continuation of hormone treatment may be an issue that transgender youth face when incarcerated. Whether these teens arrive at a juvenile justice facility receiving medications to suppress puberty or are taking cross-gender hormones, they frequently require ongoing medical hormonal treatment. Facility clinicians may need to contact the teen's outside practitioner for guidance in managing hormone therapy.
      Institutional administrators should provide training for staff and develop and implement policies and procedures to protect incarcerated LGBT youth. In addition, trained staff should provide education to all youth to promote and maintain a culture of support and understanding, to prevent and respond to potential bullying [

      National Commission on Correctional Health Care Board of Directors. Position Statements: Transgender health care in correctional settings. http://ncchc.org/resources/statements/transgender.html; 2009.

      ]. Recent guidelines provide policy guidance for serving transgender and gender-nonconforming youth in group care facilities, including detention and correctional facilities [
      • Feinstein R.
      • Greenblatt A.
      • Hass L.
      • et al.
      Justice for all? A report on lesbian, gay bisexual and trans-gendered youth in the New York Juvenile Justice System.
      ,
      • Marksamer J.
      • Spade D.
      • Arkles G.
      A place of respect: A guide for group care facilities serving transgender and gender non-conforming youth.
      ].
      Juvenile justice facilities should work with the local public health community so that appropriate expertise can be developed within the institution. At the time of release, LGBT youth should also be referred to appropriate programs that will help them successfully adjust after release.

      Reparative therapy

      Sexual orientation conversion therapy or reparative “therapy” refers to the practice of attempting to change an individual's sexual orientation and attractions from members of the same gender to those of the opposite gender. In 1973, “homosexuality” was removed from the Diagnostic and Statistical Manual of Mental Disorders, thus eliminating it as a mental disorder [
      • Bayer R.
      Homosexuality and American psychiatry: The politics of diagnosis.
      ].
      In 2000, the American Psychiatric Association issued a position statement opposing the practice of reparative therapy [

      American Psychiatric Association. Therapies focused on attempts to change sexual orientation reparative or conversion therapies. http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/200001.aspx; 2000.

      ], and augmented its 1998 statement, which stated:The potential risks of reparative therapy are great, including depression, anxiety and self-destructive behavior, since therapist alignment with societal prejudices against homosexuality may reinforce self-hatred already experienced by the patient. Therefore, the American Psychiatric Association opposes any psychiatric treatment, such as reparative or conversion therapy which is based upon the assumption that homosexuality per se is a mental disorder or based upon the a priori assumption that the patient should change his/her sexual homosexual orientation [

      American Psychiatric Association. Psychiatric treatment and sexual orientation. http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/200001.aspx; 1998.

      ].
      In 2009, the American Psychological Association published a resolution advocating against reparative therapy after conducting an extensive study that evaluated 83 research studies. They concluded that the efficacy of reparative therapy was poor and, in many cases, harmful [
      • APA Task Force on Appropriate Therapeutic Responses to Sexual Orien-tation
      Report of the Task Force on Appropriate Therapeutic Responses to Sexual Orientation.
      ]. The American Psychological Association further reinforced that same-sex attractions are a normal variant of sexuality, and recommended that practitioners avoid reparative therapy as a viable treatment option [
      • APA Task Force on Appropriate Therapeutic Responses to Sexual Orien-tation
      Report of the Task Force on Appropriate Therapeutic Responses to Sexual Orientation.
      ]. In addition, global organizations such as the Pan American Health Organization have condemned reparative therapy, stating that “Purported therapies aimed at changing sexual orientation lack medical justification and are ethically unacceptable” [

      Pan American Health Organization. “Therapies” to change sexual orientation lack medical justification and threaten health.” http://new.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=17703&Itemid.

      ].
      The Society for Adolescent Health and Medicine firmly believes that LGBT adolescents fundamentally experience the same physical, developmental and emotional hurdles as do their non-LGBT adolescent peers. However, non-acceptance or victimization by peers, family members, or their community creates an added dimension of stress, which can lead to mental health problems and/or high-risk behaviors. Because reparative therapy is an unsubstantiated and harmful option, it should not be considered or recommended for teenagers who are dealing with issues surrounding their sexual orientation or gender identity. Rather, providers who work with teens should be trained to recognize the adolescent's external stressors, which may increase risks, and provide supportive counseling to promote self-acceptance and healthy growth.
      Prepared by:
      David S. Reitman, M.D., M.B.A.
      Georgetown University School of Medicine
      Georgetown University Hospital
      Washington, DC
      Bryn Austin, Sc.D.
      Harvard University School of Public Health
      Children's Hospital Boston
      Boston, Massachusetts
      Uri Belkind, M.D.
      Albert Einstein College of Medicine
      St. Barnabus Hospital
      Bronx, New York
      Tonya Chaffee, M.D., M.P.H.
      University of California at San Francisco
      San Francisco General Hospital
      San Francisco, California
      Neal D. Hoffman, M.D.
      Albert Einstein College of Medicine
      Children's Hospital at Montefiore
      Bronx, New York
      Eva Moore, M.D.
      University of British Columbia
      British Columbia Children's Hospital
      Vancouver, British Columbia, Canada
      Robert Morris, M.D.
      David Geffen UCLA School of Medicine
      Ronald Reagan UCLA Medical Center
      Los Angeles, California
      Joanna Olson, M.D.
      University of Southern California
      Children's Hospital Los Angeles
      Los Angeles, California
      Caitlin Ryan, Ph.D., A.C.S.W.
      San Francisco State University
      Family Acceptance Project
      San Francisco, California

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