Key points

Lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth, a group including nonheterosexual, gender-nonconforming, and gender-dysphoric children, adolescents, and young adults on multiple developmental trajectories toward LGBT adulthood, are more likely than their peers to experience stigma in the health care environment. Providing care that is affirming and inclusive, that is, care that draws on knowledge and skills enabling a health care provider to work effectively with LGBTQ youth, is critical to improve health outcomes and quality. The broader clinical environment, clinic flow and other organization functions, and administrative systems also need to be considered so as to ensure that clinical services are welcoming. Increasingly, examining these components and the messages they send to LGBTQ youth is not simply good care, but should be the baseline standard that health care organizations apply. This is particularly important because prevalence estimates reveal that LGBTQ youth are inevitably a part of every general medical practice, whether providers realize it or not.

This article begins by reviewing special considerations for the care of LGBTQ youth, then turns to systems-level principles underlying inclusive and affirming care. It then examines specific strategies that individual providers can use to provide more patient-centered care, and concludes with a discussion of how clinics and health systems can tailor clinical services to the needs of LGBTQ youth.

Special considerations in lesbian, gay, bisexual, transgender, and questioning youth care

Ensuring high-quality care for LGBTQ youth requires providers to understand principles of caring for LGBTQ individuals as well as those of caring for young people more generally. Although most LGBTQ youth are physically and mentally healthy, certain LGBTQ youth are at elevated risk of human immunodeficiency virus (HIV) infection, sexually transmitted infection (STI), pregnancy, obesity, substance use disorders, mood and anxiety disorders, eating disorders and other body image-related concerns, peer bullying (see Valerie A. Earnshaw and colleagues’ article, “ LGBT Youth and Bullying ,” in this issue), and family rejection (see Sabra L. Katz-Wise and colleagues’ article, “ LGBT Youth and Family Acceptance ,” in this issue). LGBTQ youth may avoid seeking health care due to fear of discrimination, and even once in care, may fear disclosure of their sexual orientation or gender identity and therefore withhold truthful responses from their health care providers. Transgender youth face the added burden of locating providers with sufficient knowledge, competence, and experience to affirm their gender identity. LGBTQ youth are also disproportionately more likely to be homeless, and in many cases, this may be due to parental rejection or other trauma.

Critical to understanding care of LGBTQ individuals and underlying many of these health disparities is stigma (see Mark L. Hatzenbeuhler’s and John E. Pachankis’ article, “ Stigma and Minority Stress as Social Determinants of Health Among LGBT Youth: Research Evidence and Clinical Implications ,” in this issue). Stigma is defined as the labeling of a specific group, and associated stereotyping, separation, status loss, and discrimination. Both interpersonal (ie, stigma between patients and other people, which in the health care setting may include providers and other clinic staff) and structural stigma (ie, stigma resulting from systems and organizations, which in the health care setting may include the clinical environment, clinic flow, and other functions) have been barriers to inclusive and affirmative care for this population.

As an example of how stigma affects the health of youth, rejection of an LGBTQ individual by his or her parents (see Sabra L. Katz-Wise and colleagues’ article, “ LGBT Youth and Family Acceptance ,” in this issue) may lead to separation and isolation, loss of resources (such as housing, food, clothing, and money), disadvantaged financial and social status, and ongoing discrimination. The links to social determinants of health (such as homelessness and poverty) and to adverse health outcomes (such as mood and anxiety problems, and substance use and related harms) are obvious. Stigma adversely affects LGBTQ youth, and is perpetuated in some health care settings. This is perhaps not surprising given the current lack of attention to educating medical students, trainees, and clinicians about issues related to LGBTQ health.

Ensuring inclusive and affirmative health care environments for LGBTQ youth also requires in-depth understanding of general issues pertinent to caring for all children, adolescents, and young adults. Youth have unique physiologic, neurocognitive, and psychosocial needs; accordingly, their care should be developmentally appropriate to these. Appropriate handling of youths’ confidentiality is important; when sensitive information is disclosed by LGBTQ youth, it is a matter of paramount importance, discussed later in this article. For youth in the process of transition from pediatric to adult clinical services, care can become fragmented.

Youth often use language pertaining to sexual orientation and gender identity that may be unfamiliar to health care providers. Currently, there is expansive thinking about both sexual orientation and gender identity, particularly among youth. Many in the LGBTQ community even reject the terms lesbian, gay, bisexual, and transgender as not capturing all sexual orientations or gender identities. For example, many youth describe themselves as queer, an umbrella term inclusive of all nonheterosexual sexual orientations and non–cis-gender identities. Some youth describe themselves as pansexual, asexual, or aromantic regarding sexual orientation. Gender identity is often thought of as outside the traditional male-female binary and on a spectrum; many youth self-describe as gender-nonconforming (defined in this issue as nonconformity in gender role expression, but sometimes used by youth differently to refer to gender identity variance) and use terms such as “gender-queer” or “gender-nonbinary.” These issues, and how providers and their organizations can address them to generate LGBTQ youth-affirming clinical services, are outlined in subsequent sections.

Special considerations in lesbian, gay, bisexual, transgender, and questioning youth care

Ensuring high-quality care for LGBTQ youth requires providers to understand principles of caring for LGBTQ individuals as well as those of caring for young people more generally. Although most LGBTQ youth are physically and mentally healthy, certain LGBTQ youth are at elevated risk of human immunodeficiency virus (HIV) infection, sexually transmitted infection (STI), pregnancy, obesity, substance use disorders, mood and anxiety disorders, eating disorders and other body image-related concerns, peer bullying (see Valerie A. Earnshaw and colleagues’ article, “ LGBT Youth and Bullying ,” in this issue), and family rejection (see Sabra L. Katz-Wise and colleagues’ article, “ LGBT Youth and Family Acceptance ,” in this issue). LGBTQ youth may avoid seeking health care due to fear of discrimination, and even once in care, may fear disclosure of their sexual orientation or gender identity and therefore withhold truthful responses from their health care providers. Transgender youth face the added burden of locating providers with sufficient knowledge, competence, and experience to affirm their gender identity. LGBTQ youth are also disproportionately more likely to be homeless, and in many cases, this may be due to parental rejection or other trauma.

Critical to understanding care of LGBTQ individuals and underlying many of these health disparities is stigma (see Mark L. Hatzenbeuhler’s and John E. Pachankis’ article, “ Stigma and Minority Stress as Social Determinants of Health Among LGBT Youth: Research Evidence and Clinical Implications ,” in this issue). Stigma is defined as the labeling of a specific group, and associated stereotyping, separation, status loss, and discrimination. Both interpersonal (ie, stigma between patients and other people, which in the health care setting may include providers and other clinic staff) and structural stigma (ie, stigma resulting from systems and organizations, which in the health care setting may include the clinical environment, clinic flow, and other functions) have been barriers to inclusive and affirmative care for this population.

As an example of how stigma affects the health of youth, rejection of an LGBTQ individual by his or her parents (see Sabra L. Katz-Wise and colleagues’ article, “ LGBT Youth and Family Acceptance ,” in this issue) may lead to separation and isolation, loss of resources (such as housing, food, clothing, and money), disadvantaged financial and social status, and ongoing discrimination. The links to social determinants of health (such as homelessness and poverty) and to adverse health outcomes (such as mood and anxiety problems, and substance use and related harms) are obvious. Stigma adversely affects LGBTQ youth, and is perpetuated in some health care settings. This is perhaps not surprising given the current lack of attention to educating medical students, trainees, and clinicians about issues related to LGBTQ health.

Ensuring inclusive and affirmative health care environments for LGBTQ youth also requires in-depth understanding of general issues pertinent to caring for all children, adolescents, and young adults. Youth have unique physiologic, neurocognitive, and psychosocial needs; accordingly, their care should be developmentally appropriate to these. Appropriate handling of youths’ confidentiality is important; when sensitive information is disclosed by LGBTQ youth, it is a matter of paramount importance, discussed later in this article. For youth in the process of transition from pediatric to adult clinical services, care can become fragmented.

Youth often use language pertaining to sexual orientation and gender identity that may be unfamiliar to health care providers. Currently, there is expansive thinking about both sexual orientation and gender identity, particularly among youth. Many in the LGBTQ community even reject the terms lesbian, gay, bisexual, and transgender as not capturing all sexual orientations or gender identities. For example, many youth describe themselves as queer, an umbrella term inclusive of all nonheterosexual sexual orientations and non–cis-gender identities. Some youth describe themselves as pansexual, asexual, or aromantic regarding sexual orientation. Gender identity is often thought of as outside the traditional male-female binary and on a spectrum; many youth self-describe as gender-nonconforming (defined in this issue as nonconformity in gender role expression, but sometimes used by youth differently to refer to gender identity variance) and use terms such as “gender-queer” or “gender-nonbinary.” These issues, and how providers and their organizations can address them to generate LGBTQ youth-affirming clinical services, are outlined in subsequent sections.

Systems-level principles underlying lesbian, gay, bisexual, transgender, and questioning youth-friendly services

The World Health Organization and other leading professional organizations have highlighted principles that should underlie all youth-friendly care, and in addition, there are a number of technical reports and clinical practice guidelines to help clinicians apply these principles specifically to the care of LGBTQ youth. Recognizing the unique biological, developmental, and psychosocial needs of children, adolescents, and young adults, and especially those who are LGBTQ, health services for youth should be optimized with regard to availability , accessibility , acceptability , and equity .

Availability refers to the presence of health care providers with knowledge, competence, and experience working with young people with current or developing LGBTQ identities, feelings, or behavior. Accessibility is the relative ease with which LGBTQ youth can obtain care from an available provider. Acceptability is the extent to which clinical services are culturally competent and developmentally appropriate for LGBTQ youth, and as a critical component of this, the degree to which parents are involved when appropriate (especially in the care of younger children) and confidentiality is ensured and protected with youth while maintaining collaborative relationships that include appropriate boundaries with parents, other guardians, community members like school personnel, and colleagues. Equity refers to the extent to which clinical care and services are friendly to all LGBTQ youth, regardless of sexual orientation, gender expression, gender identity, race, ethnicity, language, ability to pay, housing status, and insurance status, among other factors. Each of these principles is reviewed in the following sections and summarized in Table 1 .