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Adolescent sexual orientation

Reaffirmed: Feb 1 2014

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Principal author(s)

M Kaufman; Canadian Paediatric Society, Adolescent Health Committee
Paediatr Child Health 2008;13(7):619-23

Introduction

Most adolescents and adults identify themselves as heterosexual. However, paediatricians and other health care providers must be aware of the significant psychological, social and medical issues that face young people who are gay, lesbian or bisexual. Almost all of these issues arise from the stigmatization that these youth face, rather than from the orientation itself [1][2].

Sexual orientation is not a diagnosis, and it is not the paediatrician’s job to discover what the teen’s orientation is. Rather, the practitioner must create an environment in which the adolescent can discuss any questions or worries that they have, whether they identify themselves as homosexual, have found that they are attracted to people of the same gender, have had a sexual encounter with someone of the same gender or are confused about their feelings. The present paper reviews the relevant definitions, epidemiologies and approaches when working with gay, lesbian and bisexual youth.

Statistics and definitions

Sexual orientation refers to whether a person’s physical and emotional arousal is to people of the same or opposite sex. One does not have to be sexually active to have a sexual orientation. Sexual and affectational preferences are not always congruent. Those who are attracted primarily to the opposite sex are heterosexual, those attracted primarily to the same sex are homosexual (gay or lesbian) and those who are attracted to both sexes are bisexual.

Studies that try to define the percentage of teens who are not heterosexual are often limited by the questions that they ask. Teens who will eventually identify as gay, lesbian or bisexual do not always do so during adolescence. Having had sex with someone of the same gender does not always mean the teen is gay, and many gay teens have never had sex with someone of the same gender. The best available Canadian statistics are from the 2003 British Columbia Adolescent Health Survey [3], a cluster-stratified, weighted survey that represented 289,767 students from British Columbia who were enrolled in public schools. While only 1.5% of all boys identified themselves as bisexual, mostly homosexual or 100% homosexual, 3.5% of sexually active boys said that they have had sex with someone of the same gender in the past year. Three per cent of girls identified as bisexual, mostly homosexual or 100% homosexual, while 6.4% of sexually active girls reported having had sex with someone of the same gender in the past year [3]. American data are similar; Remafedi et al [4] reported that 1.1% of teens identified as gay or bisexual, but 4.5% stated that their main sexual attraction was to individuals of the same sex. A Massachusetts (USA) study [5] found that 2.5% of youth self-identified as gay, lesbian or bisexual.

The process of declaring a homosexual identity is often referred to as ‘coming out’. It can start with homosexual fantasies or dreams, with the realization that one is attracted to people of the same gender, with a feeling that one is different from one’s peers or even with a sexual experience. The teen may experience identity confusion at this point, being aware of same-sex attractions but in turmoil about it. This confusion is influenced by the stigma attached to homosexuality, inaccurate knowledge, lack of role models and minimal opportunity to socialize with other youth who are having similar feelings. Further confusion may result if the youth also experiences some opposite-sex attractions. The teen may not acknowledge their orientation, avoid thinking about it or come up with an alternate explanation for their feelings [6]. The challenge for gay and lesbian youth is to develop a healthy and integrated identity in the context of negative stereotypes and prejudice, often without family or societal support. It is important to distinguish between the youth who is gay and the youth with a possible gender identity disorder. The majority of both heterosexuals and homosexuals have an identity of being male or female that matches their anatomy. People whose gender identity does not match their anatomy are often referred to as transgendered, and need specialized consultation for a possible gender identity disorder. Those who are transgendered can be heterosexual, homosexual or bisexual. The medical and psychological needs of transgendered youth are many and beyond the scope of the present paper.

Young people who are transvestites are sometimes, but not always, gay. Transvestites get pleasure from dressing in the clothing of the opposite sex. They can be heterosexual, homosexual or bisexual.

Psychological and social issues

Gay and lesbian adults often describe their adolescence as a time when they felt isolated, ashamed and afraid of being discovered that they were different – all of which can have an impact on self-esteem and identity formation [7][8]. Sadly, studies have shown that almost one-half of gay men and one-fifth of lesbians were verbally or physically assaulted in high school because of their orientation [9][10], and that they were two to four times more likely to be threatened with a weapon at school [5][11]. Harassment at school leads to a higher risk of dropping out of school. Gay teens can also be harassed at home, and are more likely to be kicked out of their homes and living on the streets than their heterosexual peers [12].

Young people from ethnic or racial minorities may be at increased risk, with feelings of vulnerability and a perception of increased stress [13]. Homosexuality may be more stigmatized within some ethnic communities.

Gay youth are more likely to start using tobacco, alcohol and other substances at an earlier age [12]. ‘Club drugs’ such as 3,4-methylenedioxy-N-methylamphetamine (also known as ecstacy), crystal methamphetamine and ketamine are of particular concern, because youth who identify as gay seem to be at a higher risk for their use; these drugs are often associated with other high-risk behaviours [14][15]. Possible reasons for increased risk may include self-medication for depression and low self-esteem, or increased tendency toward risk behaviours in response to rejection by family and peers. The easiest place for a teen to find people who are gay is at gay bars, where drinking and smoking are part of the environment, or at clubs or raves, where club drugs are similarly integral to the culture.

High school students who say they are gay, lesbian or bisexual, or who say they are attracted to people of the same sex or have sex with people of the same sex, are two to seven times more likely to attempt suicide [16][17][18]. The risk appears to be highest when a teen acquires a gay identity at a young age, when there is a family conflict, if the teen has run away or been thrown out of the house, if he or she is conflicted about his or her orientation, or if he or she has not been able to disclose his or her orientation to anyone [19]. The data are not as strong on completed suicides, but there is evidence that a disproportionate number of suicides are among homosexuals [19]. Practitioners should inquire about sexual orientation when seeing a depressed teen and provide support for teens who are in the process of ‘coming out’.

Family issues

Teens who are in the process of coming to a homosexual identity may agonize about telling their parents. They often hate the idea that they are lying, by omission, to their parents, but also worry about how their parents will react. They may ask their paediatrician or family doctor for their advice. The teen can be helped to explore their parents’ possible reactions by thinking about how they talk about gay people, how they interact with gay people they meet and how they deal with unexpected information. Some parents suspect that their teen is gay, but may feel as awkward as the teen in bringing it up. Teens can introduce the subject of homosexuality by bringing up a book that they are reading or something that is in the news, and seeing what their parents have to say. Many teens tell a sibling or cousin before they tell a parent, and often an adolescent chooses one parent to tell first. Role playing can help the teen to find the words that they want to use with their parents and the words that they want to avoid so not to imply that they are communicating terrible news. They can reassure their parents that they are the same person they always were. Not all teens should tell their parents about their orientation, and others may want to wait a while after making a decision to disclose their sexual identity, given the possible negative repercussions [9]. Under no circumstances is it appropriate for the physician to disclose this information without a teen’s consent. If disclosure about an adolescent’s suicidality becomes necessary, the role of sexual orientation in the suicidal ideation does not have to be revealed to the parents if the teen does not want the information shared.

Parents may approach the paediatrician when their teen has ‘come out’ to them. It is not uncommon for them to ask the paediatrician for reassurance that the teen is going through a phase and may not actually be gay. It is appropriate to tell parents that teens who have chosen to come out to their parents are likely quite certain about their homosexual orientation. Parents should be told that it is important that they let their teen know that they still love them while they are dealing with their feelings about orientation. Conversion or reparative therapy, where attempts are made to turn gay males or lesbians into heterosexuals, are clearly unethical and should not be provided by physicians, nor should physicians refer patients for such therapy [20]. Many Canadian cities have a chapter of Parents and Friends of Lesbians And Gays (PFLAG), an organization that has helped many parents whose children have come out to them <http://www.pflagcanada.ca/>.

Relationship issues

All adolescents are in a process of learning to relate to peers as friends, as well as potential romantic and sexual partners. This can be more complicated for gay, lesbian and bisexual teens, who often lack models of same-sex relationships. How to meet someone who may be interested, how to flirt, what to do on a date or how to introduce a sexual element to the relationship are all things that may mystify a young person. The stakes are high – if a heterosexual male teen asks a girl out and she says no, he might feel rejected, but he does not risk being labelled as a pervert or being assaulted. Gay youth support groups often address these issues.

The recent political and legal changes in Canada regarding same-sex marriages may have a positive impact on the well-being of homosexual and bisexual youth. The knowledge that they can get married may help teens feel less stigmatized and more a part of the mainstream. It may also help some parents accept their teen’s orientation because they are able to envision a more conventional future for their child. Statistics are not available on the numbers of adolescents who have married same-sex partners. Very few people 18 years of age or younger get married, and parental consent is required for those younger than 18 or 19 years of age (depending on the province or territory).

Medical issues

Gay, lesbian and bisexual youth have the same diversity of health care needs as heterosexual adolescents, including chronic illness, disabilities, sports injuries and even contraception. They come from all ethnic groups, social classes and racial backgrounds. While it is important to consider the teen’s sexual orientation when providing care, it is also vital to remember that they may have health care needs that are not associated with their sexual orientation.

Gay and lesbian young people are at an increased risk of sexually transmitted infections (STIs) because they are more likely to have had sexual intercourse, with more partners, and to have had nonconsensual intercourse [12]. Women who are not intravenous drug users and who have sex only with other women have the lowest risk for HIV and other STIs than any group of sexually active people. However, many sexually active lesbian adolescents have had sexual intercourse with males [3][21]-[23].

Gay males are not all sexually active, and of those who are, not all have anal intercourse. Erroneously, some teens get the idea that they cannot really be gay unless they have anal intercourse. Unprotected anal intercourse puts the teen at risk for HIV, parasites, human papillomavirus (HPV), and hepatitis A, B and C. Gay males should be assessed for their risk of STIs. A full workup is not always (or even usually) warranted, but would include urethral (or urine), pharyngeal and anal swabs for gonorrhea, urethral culture or urine for chlamydia, venereal disease research laboratory testing, anal cytology, stool culture testing, ova and parasite, and HIV testing.[24]

Lesbian teens who have had sex with males should have routine screening for STIs. Consideration should also be given to STI screening if penetrating sex toys have been used in teens having sex with either gender.[25] Pap smears are no longer routinely recommended in Canadian adolescent females.[26] The paediatrician can explain contraceptive options and prescribe ‘advance of need’ emergency contraception for those lesbians who may have sex with men. Both male and female teens may have questions about future reproductive options, although few gay or lesbian teens plan to have children in the near future.

HPV immunization is approved in Canada for both genders,[27] although public funding of the vaccine is not available in all jurisdictions. Education and counselling about immunization should be included in preventive care for these teens.

The approach to the teen

For all teens, an environment that feels safe is of key importance. This includes an explanation of confidentiality. Fear of a lack of confidentiality is a significant barrier to adolescents disclosing anything of a personal nature [28]. Teens should be given the opportunity to discuss issues of sexual attraction and orientation, mental health, substance and alcohol use, safer sex, school, family and friends. Many clinicians use the well-known HEADS interview with teens, covering home, education, activity, affect, drugs and sexuality. With all adolescents, sexual history should be done in a gender-neutral manner. Asking, ‘Is there anyone you are romantically interested in?’ and ‘Have you ever had sex with anyone?’ gives any teen more latitude in his or her answers, and provides a subtle acknowledgement that there are many possible answers. Another good question to ask any teen is ‘When you think of people to whom you are sexually attracted, are they men, women, both, neither or are you not sure yet?’ [29]. The occasional patient who is insulted by this question can be educated about sexual orientation.

Many physicians receive little training in talking to teens about sex and sexual orientation. Many still address these issues; however, the clinician who is uncomfortable talking about these issues should consider transferring their adolescent patients to another physician.

The office environment can be welcoming to all teens, with brochures on a wide variety of adolescent topics, including sexual orientation; posters that show both same-sex and opposite-sex couples; notices about support group meetings; forms that are gender neutral; and office staff who are sensitive to the needs of teens and who do not make critical or derogatory comments about sexual orientation.

Medical education

Paediatricians often have an opportunity to teach medical students and residents in their offices or hospital practices. There are often clinical situations in which topics such as adolescent sexuality, gay and lesbian parenting, as well as counseling parents about sexual orientation are clinically relevant. These ‘teachable moments’ provide a natural way to discuss these topics. Gay or lesbian students may disclose their own sexual orientation to a preceptor or mentor after an open discussion of these issues.

Beyond the individual

Paediatricians have many opportunities to effect change within their communities. They can ensure that the institutions that they work in treat all teens equally and without bias. Schools, school boards and community organizations can be helped to see these as important issues, and encouraged to provide education and materials about sexual orientation. Paediatricians can provide expertise to support groups and can even help to create these groups. They can speak with their colleagues about these issues.

Recommendations

The Canadian Paediatric Society recommends that:

  • Comprehensive health care aimed at promoting normal adolescent development, social and emotional well-being, and physical health be available to adolescents of all sexual orientations.
  • History-taking should avoid making the assumption of heterosexuality, with questions about romantic and sexual partners asked in a nongendered way.
  • If a health care provider has personal barriers to providing nonjudgmental care and information, they should refer patients to another provider.
  • Health care providers should stay informed about resources in their communities for gay and lesbian adolescents.
  • Providers should be aware of the risks to health and development in these youth, including those resulting from homophobia or from sexual behaviours.
  • Education and counseling should be available to all youth to prevent the spread of HIV, HPV and STIs.
  • Adolescents with suicidal ideation should be urgently referred to a mental health specialist. Homosexual adolescents with significant depression, anxiety or substance abuse issues should be referred, whenever possible, to mental health specialists with experience treating homosexual adolescents. Conversion and reparative therapies should not be provided because they do not work, and have the potential to heighten guilt and anxiety.

ADOLESCENT HEALTH COMMITTEE

Members: Franziska Baltzer MD; April Elliott MD; Debra Katzman MD; Jorge Pinzon MD (chair); Koravangattu Sankaran MD (board representative); Danielle Taddeo MD
Liaisons: Sheri M Findlay MD, CPS Adolescent Health Section, Johanne Harvey MD, CPS Adolescent Health Section
Principal author: Miriam Kaufman MD

References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.