Wednesday, August 14, 2013

Best Practices to Identify Gay, Lesbian, Bisexual, or Questioning Youth in Primary Care

Kyle C. Chaplic, MSN, APRN, NP-C, Patricia Jackson Allen, MS, RN, PNP-BC, FAAN
Pediatr Nurs. 2013;39(2):99-103.


Compared to heterosexual youth, gay, lesbian, bisexual, and questioning (GLBQ) adolescents engage disproportionately in a variety of health risk behaviors and are at risk for numerous negative health outcomes. Adolescents reporting same-sex sexual attraction, romantic relationships, and sexual experience are also at increased risk, regardless of self-identified sexual orientation. While adolescents feel it is important to discuss sexuality with primary care providers, they are unlikely to initiate discussion about sexuality or to openly disclose GLBQ sexual orientation to their providers. Primary care providers should identify GLBQ youth to increase delivery of targeted preventive health services to this at-risk population. However, providers do not routinely address sexual orientation in their clinical encounters with adolescents, and the majority of GLBQ youth are not identified in the primary care setting. To better serve the needs of this population, providers should initiate open, sensitive, nonjudgmental, and confidential discussion of sexuality with all adolescents. Providers should inquire about sexual orientation, sexual attraction, romantic relationships, and sexual partners.


Healthy People 2020 states that gay, lesbian, bisexual, and transgender (GLBT) health "requires specific attention from health care and public health professionals to address a number of disparities," including mental health and suicidal behavior (U.S. Department of Health and Human Services, 2012). In addition to the usual issues faced by all adolescents, GLBT and questioning (GLBTQ) adolescents must also face the persistent social stigma associated with sexual minorities in America. In a recent study, 3.4% of male and 9.5% of female adolescents 14 to 17 years of age self-identified as gay, lesbian, bisexual, or "other" (Herbenick et al., 2010).
It is clear that GLBQ adolescents constitute a vulnerable subpopulation of adolescents in which particular vigilance in health promotion and disease prevention is required. However, these youth are often "invisible" to pediatric primary care providers (Frankowski & the American Academy of Pediatrics [AAP] Committee on Adolescents, 2004). To better meet the unique health care needs of this population, providers must be able to sensitively elicit a detailed and accurate social and sexual history from adolescents to identify these youth. This clinical article synthesizes pertinent recent research pertaining to social and sexual history taking in GLBQ adolescents to increase identification of these youth in primary care practice.A 2011 Centers for Disease Control and Pre vention (CDC) report concluded that "compared to students who are not sexual minorities, a disproportionate number of sexual minority students engage in a wide range of health risk behaviors" (CDC, 2011b, p. 49). A number of previous studies have also shown that these youth are at significantly increased risk for victimization and violence, mental health problems and substance abuse, a variety of health risk behaviors, and suicide (Bontempo & D'Augelli, 2002; Faulkner & Cranston, 1998; Garofolo, Wolf, Kessel, Palfrey, & DuRant, 1998; King et al., 2008; Robin et al., 2002; Russell & Joyner, 2001).

Discussion and Recommendations

Given the increased prevalence of health risk behaviors in GLBQ adolescents demonstrated in the literature, it is important to identify these youth, contrary to the AAP position (Frankowski & AAP Committee on Adolescents, 2004) to provide additional counseling and health care services. These youth would be better served by primary care providers if their sexual orientation was identified in a supportive, confidential environment where services were available to address their health care needs. Key findings and recommendations for sensitive sexual history taking to identify GLBQ youth based upon the review of the literature are outlined in Table 2.

Recommendations for Sensitive Care of GLBQ Adolescents

While it is important to recognize that GLBQ youth are an at-risk population, it is essential that providers avoid a narrow view of these adolescents and provide them with the same sensitive, individualized, comprehensive care as they would other adolescents (Catallozzi & Rudy, 2004; Coker, Austin, & Schuster, 2010; Garofolo & Katz, 2001). GLBQ adolescents value the same characteristics in providers and clinical settings as other adolescents (Ginsburg et al., 2009; Hoffman et al., 2002; Rosenthal et al., 1999). Current guidelines for adolescent care should be followed, and counseling should be based on individual risk factors, not solely sexual orientation (Coker et al., 2010).
A number of resources are available online and in print that clinicians may find useful in developing their skills with GLBQ individuals. One such guideline is the Gay and Lesbian Medical Association'sGuidelines for Care of Lesbian,Gay, Bisexual, and Transgender Patients (Dunn et al., 2006). Although lacking in evidence-based preventive care guidelines, it contains a wealth of useful information on how to sensitively interact with GLBQ individuals and how to create a welcoming, inclusive practice environment. Additionally, the Gay and Lesbian Medical Association's guideline recommends that providers 1) avoid assumptions about adolescents and their sexual orientation or sexual practices, including assumptions of heterosexuality; 2) use inclusive, gender-neutral language on forms and in adolescent interviews; 3) observe and reflect language and terminology used by adolescents; 4) initiate open discussion of sexual history; and 5) use open-ended questions (see Figure 1). To help create a welcoming, inclusive practice environment, the Gay and Lesbian Medical Association recommends creating, posting, and enforcing a nondiscrimination policy (Dunn et al., 2006). Further, although the display of support symbols, brochures, and education materials pertinent to GLBQ youth are far less important to GLBQ adolescents than provider sensitivity (Ginsburg et al., 2002), the Gay and Lesbian Medical Association recommends the display of such materials (Dunn et al., 2006).

Bright Futures

AAP's Bright Futures Guidelines for Health Supervision ofInfants, Children, and Adolescents (Hagan, Shaw, & Duncan, 2008) is widely used and considered to be the standard of care in the provision of pediatric preventive health care in the United States. Providers using Bright Futures, however, should be aware that the guidelines contain limited information on the care of GLBQ adolescents; they echo the findings of Frankowski and AAP Committee on Adolescents (2004) and are not consistent with recommendations based upon this literature review.
The Bright Futures forms may be used to encourage discussion, but providers must be aware of their deficiencies in regard to eliciting sexual orientation or attraction in youth. It is particularly important that adolescents who indicate they are not sexually active still be interviewed regarding sexuality regardless of the forms' instruction to skip to the next section. Providers should review all adolescent history forms or electronic medical records used in their practice to determine their appropriateness for obtaining confidential, unbiased, sexual orientation and practice histories.Bright Futures health history forms for teens 11 to 14 years of age do not address sexual activity directly, but they include a box to check to indicate if the young adolescent has questions for the provider about sexuality. Forms for middle (15 to 17 years of age) and older (18 to 21 years of age) adolescents ask if the adolescent has ever had sex (a term often interpreted to apply only to sexual intercourse, not all forms of sexual activity), but they also instruct adolescents to skip the rest of the section if their response is "no." These forms ask males if they have "ever had sex with other men," but do not inquire about same-sex activity in females. No questions pertain to relationships of any kind nor same-sex attraction (Hagen et al., 2008).

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