CHAPTER 57
Culturally Competent Care for Diverse Populations: Sexual Orientation and Gender Expression
Ilana Sherer, MD, FAAP; Brittany Allen, MD, FAAP; Joseph H. Waters, MD; and Lynn Hunt, MD, FAAP
CASE STUDY
The mother of an 11-year-old boy makes an appointment with you to discuss her son’s “behavior problems.” He is the youngest of 4 children and is doing well in fifth grade, but she is concerned that her son does not like typical “male” activities. He dropped out of Little League, will not join other sports teams, and prefers riding his bike by himself. Additionally, he still likes dressing up in costumes and prefers playing with girls rather than boys. His mother finally mentions that she is worried that her son will be gay and is wondering what she can do to help him develop “normally.”
Questions
1. What is meant by gender expression, sexual orientation, and gender identity?
2. What is the role of the pediatrician in counseling parents and patients about gender expression, sexual orientation, and gender identity?
3. What are some of the consequences of discrimination against sexual orientation and gender identity minority populations?
4. How can the physician help families support their children who are lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ+)?
Introduction
Lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ+) individuals are members of nearly all communities. All pediatricians will have the privilege of caring for an individual from this population at some point in their career. Youth who are LGBTQ+ are a diverse and resilient population who, when supported, grow into healthy, well-adjusted adults. The stigma associated with being LGBTQ+ can result in a host of adverse health outcomes, however. The American Academy of Pediatrics position statement on caring for LGBTQ+ youth clearly states that there is nothing inherently high risk or abnormal about these youth, but that stigma often causes psychological distress, with a resultant increase in risk behaviors.
Stigma may also be encountered in health care settings. Many LGBTQ+ youth have had negative health care experiences and often do not “come out” to the health professionals they consult. As a result, pediatricians caring for these youth may not be aware of their patients’ identity. Children and adolescents of all variations of gender identity and sexual orientation will come under the care of a pediatrician during childhood and adolescence, and it is known that adult outcomes are dependent on the level of nonjudgmental support received.
Language concerning sexual orientation and gender identity is important and constantly changing. In this chapter, the most commonly used acronym, LGBTQ+, is used to refer generally to people with diverse bodies, sexual orientations, and gender identities. Longer or different acronyms are used as well, such as LGBTQIAAP+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, ally, and pansexual; see Table 57.1 for definitions), with the goal of being more inclusive and acknowledging that certain groups have not been well represented by some labels or acronyms. The plus symbol at the end of LGBTQ+ is used to indicate that this population includes but is not limited to people who identify as lesbian, gay, bisexual, transgender, and queer/questioning, and that a list of letters can never be fully inclusive.
| Table 57.1. Glossary of Terms Concerning Sex, Gender Identity, and Sexual Orientationa,b | |
Term | Definition |
Affirmed gender | An individual’s true gender identity. |
Agender | A person who does not identify as having a particular gender. |
Ally | An individual who supports and stands up for the rights of LGBTQ+ persons and communities. |
Asexual | The sexual orientation of individuals who feel little or no attraction to others. Having an asexual orientation is different from choosing to abstain from sex. |
Bisexual | The sexual orientation of individuals who develop both same-sex and opposite-sex romantic, physical, and emotional attractions. |
Cisgender | A person who identifies as and expresses a gender that is consistent with the culturally defined norms of the sex they were assigned at birth. Used as an adjective. |
FTM; affirmed male; trans male/man; transmasculine | Terms used to describe individuals who were assigned female sex at birth but whose gender identity and/or expression is asserted to be more masculine. |
Gay | An individual whose romantic, physical, and emotional attractions (ie, sexual orientation) are to persons of the same sex. Often it refers to men, but it may be used to describe a person of any sex with a same-sex orientation. Used as an adjective. |
Gender diverse/gender expansive | Umbrella terms used to describe people with gender behaviors, appearances, or identities that are incongruent with those that are culturally normative for their birth sex. Gender-diverse individuals may refer to themselves by many different terms, such as transgender, nonbinary, genderqueer, gender fluid, gender creative, gender independent, or noncisgender. Gender diverse is used to acknowledge and include the vast diversity of gender identities that exists. It replaces the formerly used term, “gender nonconforming,” which has a negative and exclusionary connotation. Children who do not yet have language to describe themselves as transgender may be referred to by others by one of these terms. |
Gender dysphoria | A clinical symptom characterized by a sense of alienation to some or all of the physical characteristics or social roles of one’s assigned gender. Gender dysphoria is also the psychiatric diagnosis in the DSM-5 that focuses on the distress stemming from the incongruence between one’s expressed or experienced (ie, affirmed) gender and the gender assigned at birth. Previous versions of the DSM included Gender Identity Disorder, which is no longer appropriate to use but may be found in older research. |
Gender expression | The diverse means of communicating one’s gender to others, such as through behavior and mannerisms, clothing, hair, voice/speech, and roles/activities. Such expression may be the result of conscious or unconscious decisions and may or may not align with social expectations for gender identity or sex assigned at birth. |
Gender identity | The internal sense of one’s own gender, which may be female, male, a combination of both, somewhere in between, or neither. Gender identity may or may not align with the social expectations for the sex an individual was assigned at birth and results from a multifaceted interaction of biologic traits, environmental factors, self-understanding, and cultural expectations. Gender identity is distinct from sexual orientation. |
Genderqueer/nonbinary | Terms to describe or name the identity of an individual whose gender identity is beyond or outside the gender binary categories of man/male and woman/female. |
Homosexual | An outdated term that refers to same-sex sexual orientation. This term is often considered abrasive and offensive. Currently preferred terms may include gay, lesbian, or queer, depending on the individual. |
Intersex/differences of sex development | An umbrella term used to describe the variety of conditions in which an individual’s physical sex characteristics (ie, external genitalia, internal anatomy, chromosomes, or hormone levels) are considered atypical based on categories of male and female. These conditions may be apparent at birth or may be diagnosed later. For some affected individuals, intersex may also be an identity. |
Lesbian | A woman whose romantic, physical, and emotional attraction (ie, sexual orientation) is to other women. May be used as an adjective or a noun. |
LGBTQ+ | Lesbian, gay, bisexual, transgender, or queer/questioning. |
MTF; affirmed female; trans female/ woman; transfeminine | Terms used to describe individuals who were assigned male sex at birth but whose gender identity and/or expression is asserted to be more feminine. |
Pansexual | An individual whose romantic, physical, and emotional attraction (ie, sexual orientation) may be to individuals of any sex or gender identity. Sometimes shortened to “pan.” |
Queer | Umbrella term used by some individuals to describe having a sexual orientation or gender identity that is beyond or outside societal norms and expectations. Although “queer” was historically a pejorative term for LGBTQ+ people, some LGBTQ+ individuals have reclaimed this term to describe their identities; however, it is not embraced by all members of the LGBTQ+ community. |
Sex | An assignment that is made at birth, usually male or female, typically based on external genital anatomy but sometimes on the basis of internal gonads, chromosomes, or hormone levels. |
Sexual orientation | A term used to describe an individual’s inherent emotional, romantic, or sexual feelings toward other persons in relation to the sex or sexes to which they are attracted. Examples of sexual orientations include but are not limited to gay, lesbian, bisexual, pansexual, asexual, heterosexual/straight, and queer. |
Transgender | An adjective used for an individual who identifies and expresses a gender that differs from the sex assigned at birth or, more generally, who experiences or expresses gender differently from what people expect. Gender identity is different from sexual orientation. Transgender individuals can be any sexual orientation, including but not limited to gay, straight, lesbian, or bisexual. The term “transgender” also encompasses many other labels individuals may use to refer to themselves. |
Abbreviations: DSM-5, Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition; FTM, female to male; MTF, male to female.
a This list is not comprehensive. It is important to recognize that language used to describe identities changes over time. PFLAG maintains a “National Glossary of Terms” at https://www.pflag.org/glossary.
b Some definitions adapted from PFLAG. National glossary of terms. PFLAG.org website. https://www.pflag.org/glossary. Accessed July 23, 2019 as well as from Rafferty J; American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4):e20182162.
With proper knowledge, skills, and understanding, every pediatrician can be equipped to help all LGBTQ+ youth grow and thrive (Box 57.1).
Incidence
It is challenging to get an accurate estimate of the number of LGBTQ+ youth in the United States. Large-scale surveys indicate that approximately 5% of the adult population identifies as LGBTQ+ or reports being in or having been in a same-sex relationship. Younger adults are more likely to identify as LGBTQ+; thus, it is likely that these percentages will continue to increase over time. The prevalence of sexual minority persons is consistent across all ethnic and socioeconomic groups. Although less research is available specifically about gender identity, studies show that 0.17% to 2.7% of youth identify as transgender or gender diverse in surveys of middle school, high school, and college students in the United States.
Gender Identity and Sexual Orientation
Gender identity, gender expression, and sexual orientation are 3 separate concepts that are often confused and sometimes inaccurately interchanged (see Table 57.1). Gender identity refers to an individual’s internal sense of self as male, female, some combination of both, an identity in between, or neither, whereas gender expression is the way in which individuals present their gender to people around them through outward markers, such as clothing, hair, and mannerisms. It is important to understand and distinguish between gender identity and gender expression. Although gender expression can vary based on cultural expectations and may be influenced by parental and peer support or rejection, gender identity is intrinsic to the self and cannot be changed by external influences.
For most people, gender identity coincides with cultural norms associated with their biologic or natal sex; the word used to describe this alignment is cisgender. For some individuals, gender identity is incongruent with cultural norms associated with their biologic sex; the word used to describe this alignment is transgender. Gender identity often develops before puberty, as young as 2 to 3 years of age. Many children display variations in gender expression and are gender expansive or gender variant throughout early childhood and into adolescence. Some of these children eventually identify as transgender and some as cisgender. Additionally, some may identify as nonbinary, genderqueer, gender-creative, or agender, meaning that their gender identity is something outside the binary of male or female.
In contrast, sexual orientation refers to an individual’s attraction to others and usually develops in late childhood and adolescence. Traditionally, individuals who experience same-sex attraction have been called gay or lesbian, those who experience opposite-sex attraction have been called heterosexual or straight, and those who experience attraction to both sexes have been called bisexual. Like all people, those who are transgender can be attracted to a person of any sex or gender, and they may identify as straight, bisexual, gay or lesbian, or something else. It is also important to note that language around sexual attraction shifts with every new generation, and currently it is common to hear youth use new terms and language to more fully describe the complexities of their sex and gender as well as to whom they are attracted.
Box 57.1. Best Practices for Creating an LGBTQ+-Friendly Office
Before the Visit
•Decorate the office with affirming rainbow stickers and posters.
•Brochures, books, and website images should represent the full spectrum of gender expressions and family structures.
•Intake forms should include space for different family structures and gender identities. The forms should include questions about preferred name and gender marker. Examples of such questions can be found here: www.ama-assn.org/delivering-care/creating-lgbtq-friendly-practice.
•Electronic medical records should represent the patient’s preferred name and pronoun.
•All office staff should be trained to use open-ended language when discussing family structure and preferred name and/or pronoun.
•Bathrooms should be gender neutral or single stall, and signage should indicate this.
During the Visit
•Provide the same level of care that you would for any patient. Use the American Academy of Pediatrics or the Society for Adolescent Health and Medicine guidelines.
•Use the appropriate pronoun and/or name.
•Discuss confidentiality. Concerns about possible disclosure often are mentioned by LGBTQ+ youth as a reason to avoid seeking health care.
•Use open-ended language during the interview. See Box 57.2 for examples of language to use to ask about sexual orientation and gender identity.
•When asking questions about identity or behavior, explain to the youth the medical reasoning behind the question. Avoid asking invasive questions only to satisfy curiosity. The physician should avoid asking the youth to be the physician’s educator about issues of sexuality and gender.
•As for all youth, it is important to know about recommendations for screening based on sexual risk behaviors and to avoid making assumptions about risk based on sexual orientation or gender identity.
•Genital examinations can be particularly traumatic for gender diverse patients. Explain the medical rationale behind the examination and allow the youth as much control over the process as possible.
•LGBTQ+ status is only 1 of the patient’s many identities and may not be the main reason for the patient’s visit. It is important to conduct routine health maintenance and devote attention to other identities important to the individual patient, such as race, religion, and chronic illness.
After the Visit
•The physician must be the patient’s advocate and help families and communities support the child. The physician can provide parents with the information offered in Box 57.3.
•If referrals are necessary, the primary care physician should call ahead to ensure that the specialist or therapist is aware and supportive of the needs of LGBTQ+ youth and families.
•The physician should advocate for LGBTQ+ youth within the school district to encourage implementation of support systems, such as peer organizations and anti-bullying policies.
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