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Working with Children/Youth who are Lesbian, Gay and Bisexual: Information for Primary Care

Summary: Physicians will encounter youth who are gay, lesbian or bisexual. Whether one is heterosexual (straight) or homosexual (gay, lesbian or bisexual), one's sexual orientation is not something that is chosen, but rather is biologically determined. Regardless of one's sexual orientation, deep down everyone simply wants the same thing -- love and acceptance. Unfortunately, due to lack of acceptance due to ignorance and discrimination, homosexual youth often experience more stress and challenges with their mental health. Health care providers can make a difference by creating a welcoming environment in which youth feel accepted, so that they can openly talk about whatever questions and concerns that they have.
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Introduction

  • Physicians will encounter youth who are gay, lesbian or bisexual.
  • Regardless of one's sexual orientation, deep down everyone simply wants the same thing -- love and acceptance.
  • Unfortunately, due to lack of acceptance due to ignorance and discrimination, homosexual youth often experience more stress and challenges with their mental health.  
  • Health care providers can make a difference by creating a welcoming environment in which youth feel accepted, so that they can openly talk about whatever questions and concerns that they have.

Terms

  • Bisexual: being physically and emotionally attracted to people of both the same and opposite sexes.

  • Gay: someone who is physically and emotionally attracted to people of the same sex. Although in the past, gay mainly referred to males, it can include both males and females.
  • LGBT: an umbrella term used to refer to people who are lesbian, gay, bisexual, transgendered, transsexual and two- spirited.
  • Heterosexual or straight: someone who is sexually and emotionally attracted to people of the opposite sex. Homosexual: being sexually and emotionally attracted to those of one's own sex. Historically, this term has had a negative connotation, so most people prefer other terms, such as lesbian, gay and bisexual.
  • Lesbian: a woman attracted sexually and emotionally to other women.
  • Transgendered: a person whose gender identity (self-identification as male, female, both or neither) does not match his/her "assigned gender" (classification by others as male or female based on genetic/physical sex). For example, a person who outwardly looks male, but who really feels like a woman on the inside. Or vice versa, a person who outwardly looks female, but who really feels like a man on the inside.
  • Transsexual: a transgendered person who has had treatments to alter the sex of his or her body.

Epidemiology

LGBT youth found that in the past year (CDC survey):
  • 8 out of 10 had been verbally harassed at school
  • 4 out of 10 had been physically harassed at school
  • 6 out of 10 felt unsafe at school
  • 1 out of 5 had been a victim of a physical assault at school
Mental Health Concerns:
  • 6 times as likely to have high levels of depression
  • > 8 times as likely to have attempted suicide
  • > 3 times as likely to use illegal drugs
  • > 3 times as likely to engage in unprotected sexual behaviours

How to create a LGBT safe environment in the office

LGBT patients will often look around the room/office in order to determine how comfortable they are sharing information with their physicians. As such, it is important to create an environment in which LGBT patients are comfortable to ask questions and talk about their concerns. Here are some things you can do:
  • Participating in provider referral programs through LGBT organizations or advertising your practice in LGBT media creates a welcoming environment before they even walk in the door
  • Have brochures, magazines or posters around the office that include relevant information for LGBT patients
  • Disseminate or visibly post a non-discrimination statement stating that equal care will be provided to all patients, regardless of age, race ethnicity, physically ability or attributes, religion, sexual orientation, or gender identity/expression
  • Acknowledge relevant days of observance in your practice such as World AIDS day, LGBT pride day, and national transgender day of remembrance.
  • Documents that patients fill out should be LGBT friendly and use gender neutral terms, eg:
  • Instead of marital status put relationship status with "partnered" as an option
    • Add a transgender option to male/female check boxes
    • Have a line for chosen name and legal name
    • Assure patients of confidentiality in the office. One may even want to distribute a written confidentiality to all patients or even post a statement up in the waiting room/examination rooms.
    • Have staff take sensitivity training and especially make sure that front-line staff know what pronouns to use when referring to a transgender patient or same sex partner, even when the patient is not present.

Language/Interviewing tips

Do's

  • Do keep the focus on care, rather than indulging your personal curiosities.
  • Do listen to your patients and how they describe their own sexual orientation, partner(s) and relationship(s), and reflect their choice of language.
  • Do ask what pronoun, word, phrase your patient prefers, if you are in doubt on how to refer to them
  • Do use the appropriate pronouns to use when referring to a transgender individual and their partner(s).

Don'ts 

  • Do not make assumptions based on one’s sexual orientation as identity does not define behaviour and vice versa, for example:
    • Just because someone identifies with a certain sexual orientation does not mean that they are sexually active.
    • Just because one identifies as homosexual does not mean that they only engage in sexual intercourse with members of their own sex (ie – just because a patient identifies as a lesbian, does not mean that she does not have sex with men).
    • Do not assume that all gay men have anal sex and are promiscuous.
  • Do not assume that lesbians won’t have children and don’t need pap smears.
  • Do not assume that all transgender individuals want to have surgery.
  • Do not use the term “gay” with patients even if they have indicated a same-sex or same-gender sexual partner.
    • If patients themselves have not indicated a particular identity or have indicated a sexual orientation other that “gay”, using this term may cause mistrust.

Primary Care Management

  • A comprehensive diagnostic evaluation should include an age-appropriate assessment of psychosexual development for all youths.
  • The need for confidentiality in the clinical alliance is a special consideration in the assessment of sexual and gender minority youth.
  • Family dynamics pertinent to sexual orientation, gender nonconformity, and gender identity should be explored in the context of the cultural values of the youth, family and community.
  • Clinicians should inquire about issues / circumstances commonly encountered by LGBT youth:
    • Bullying
    • Suicidal ideation
    • High-Risk Behaviours
    • Substance Abuse
    • HIV/AIDS and other STIs
  • Clinicians should aim to foster healthy psychosexual development in sexual and gender minority youth and to protect the individual’s full capacity for integrated identity formation and adaptive functioning.
  • Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and that attempts to do so may be harmful.
  • Clinicians should be aware of current evidence on the natural course of gender discordance and associated psychopathology in children and adolescents in choosing the treatment goals and modality.
  • Clinicians should be prepared to consult and act as a liaison with schools, community agencies, and other health care providers, advocating for the unique needs of sexual and gender minority youth and their families.
  • Clinicians should be aware of community and professional resources relevant to sexual and gender minority youth.

Family Issues

It is not uncommon for LGBT youth to be afraid to share their sexual orientation with friends and family. They will often seek advice from their family physician. Here is some helpful advice when dealing with this situation:
  • Help explore their parent’s 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
  • Teens can introduce the subject of homosexuality by bringing up a book that they are reading or something that is in the news and see what their parents have to say
  • 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
  • Sometimes the best advice for a teen is not to tell their parents about their orientation or wait a while before disclosing their sexual identity, in order to avoid negative repercussions

Privacy / Confidentiality Issues

  • Teens may request that physicians keep their sexuality confidential from parents.
  • It is not uncommon for parents to inquire about their child’s sexual orientation.
  • It is not appropriate for the physician to disclose this information without the teen’s consent.

How can family help?

Dealing with the possibility that your child is gay, or might be gay can be an extremely stressful time for many parents and families. As their physician it is important to inform parents who are struggling with the news of their child’s sexual orientation of the following:
  • There is nothing wrong in being gay, lesbian or bisexual, nor is it a mental health problem
  • The only thing that is wrong is the stigma and discrimination that people who are gay, lesbian or bisexual must face
  • Above all, accept and love your child, who is the same child as before.
  • Acknowledge your loved one's sexuality by talking about it together. Ignoring it entirely is a rejection. When you talk about your loved one's sexuality, don't reject them with one through anger or insistence that "it's only a passing phase." Ask questions about that which you don't understand.
  • Don't get upset at your loved one for having told you that s/he is gay and definitely don't get upset with them for not telling you earlier. After all, how would that make your youth feel about talking to you?
  • Offer support to your child. You might say "I love you no matter what. How can I be helpful? How can I be supportive?"
  • Get support from others. Talk with others. Talk with other parents of gay or lesbian children. Some parents feel ashamed but remember, it's not a disgrace unless you make it one. Respect your child's privacy by checking with him or her about those with whom it is acceptable to share this personal information.
  • Get your child's permission before telling others, and ask your child what s/he feels comfortable with you telling. True friends and relatives will be supportive. For those who are unsupportive, you may need to avoid or spend less time with them. If they are critical or hostile, you have a right to ask them to avoid making negative comments around you.

Online resources for parents/family

References

  • Centres for Disease Control (CDC) 
    http://www.cdc.gov/lgbthealth/youth.htm

Resources for health care providers

  • AACAP Practice Parameters - http://download.journals.elsevierhealth.com/pdfs/journals/0890-8567/PIIS089085671200500X.pdf
  • Guidelines for care of Lesbian, Gay, Bisexual, and Transgender Patients (Gay and Lesbian Medical Association)
    http://www.glma.org/document/docWindow.cfm?fuseaction=document.viewDocument&documentid=16&documentFormatId=25
  • PFLAG Canada
    http://www.pflagcanada.ca/en/help-e.html
  • Physicians for Reproductive Health’s Adolescent Reproductive and Sexual Health Education Program
    http://prh.org/teen-reproductive-health/arshep-explained/
  • American Medical Association LGBT Youth Suicide Prevention Resources
    http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt-advisory-committee/glbt-resources/lgbt-youth-suicide-prevention.page?
  • American Medical Student Association, Committee on Gender and Sexuality: Primary Care of LGBT Patients
    http://www.amsa.org/AMSA/Libraries/Committee_Docs/LGBT_PrimaryCare_1.sflb.ashx
  • Asking the Right Questions - http://www.camhx.ca/Publications/Resources_for_Professionals/ARQ2/arq2.pdf
  • Canadian Paediatric Society: Adolescent Sexual Orientation - http://www.cps.ca/documents/position/sexual-orientation

About this Document

Written by Christopher Clarkstone, Medical Student (uOttawa, Class of 2017). Reviewed by members of eMentalHealth.ca/PrimaryCare Team, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton; Michael Cheng. 

Disclaimer

This information is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your qualified expert or health provider. Always contact a qualified expert or health professional for further information in your specific situation or circumstance.

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Date Posted: Jan 24, 2017
Date of Last Revision: Jan 24, 2017

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