Assessing, monitoring, and supporting children and adolescents’ mental health are integral parts of comprehensive pediatric primary care. These are especially relevant for LGBT youth, who frequently experience unique stressors, often including having an identity different from family and peer expectations, whether to reveal it, and stigma like peer bullying, family rejection, social intolerance, and self nonacceptance. Pediatricians should know key mental health practice principles for LGBT youth, how to adapt these to various pediatric settings, the continuum of mental health interventions, and their local resources. Practice principles in pediatric care for LGBT youth and examples of their implementation are discussed.
Key points
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Mental health problems are leading causes of morbidity and mortality in all (not just lesbian, gay, bisexual, or transgender [LGBT]) youth.
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Pediatricians should monitor and support mental health in all youth.
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Like all youth, most LGBT youth are mentally healthy; however, their risk for mental health problems is somewhat elevated.
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Anti-LGBT stigma like social prejudice, peer bullying, family rejection, and self-nonacceptance are major risk factors.
Introduction
Mental health problems are highly prevalent in youth and are a significant cause of morbidity and mortality. For example, among adolescents and young adults in the United States, suicide is the third leading cause of mortality from age 10 to 14 years, and the second from age 15 to 24 years. If left unaddressed, mental health problems like depression, anxiety, disruptive behavior, and learning problems can become chronic and cause serious morbidity; however, these can be significantly ameliorated by appropriate mental health interventions. In addition to their inherent morbidity and mortality, psychiatric illnesses also may increase physical health risk behavior; for example, substance abuse (see Romulo Alcalde Aromin Jr’s article, “ Substance Abuse Prevention, Assessment and Treatment for LGBT Youth ,” in this issue) is associated with increased sexual risk behavior and exposure to sexually transmitted infections (STIs). Therefore, these are very important problems for pediatricians to know about, recognize, and address.
Most youth with psychiatric diagnoses do not receive formal mental health treatment; as a result, mental health problems in children and adolescents are often encountered first by pediatricians. The delay from the initial onset of symptoms until the start of mental health treatment can be years. According to the Agency for Healthcare Research and Quality (2009), children’s mental health disorders are among the top 5 most-costly medical conditions, costing the United States $8.9 billion annually. Therefore, pediatric primary care providers and other pediatric clinicians play a key role in detecting, assessing, and addressing youths’ mental health needs.
Lesbian, gay, bisexual, or transgender (LGBT) youth have the same pediatric and developmental needs as the general population, as well as certain LGBT-specific health and mental health needs. The ability to intervene appropriately when mental health problems exist, an important pediatric clinical competence in general, may be especially salient for youth who are or might be on a developmental path toward being LGBT. Although most lesbian, gay, and bisexual (LGB) youth are free from mental illness, a minority develops a psychiatric illness or has other mental health needs, like all youth.
The rates at which LGB youth experience certain mental illnesses, such as depression, anxiety, and substance abuse, are increased in comparison with the general population. For example, they are at twofold to fivefold risk for suicidality. This increase appears to be related to increased exposure to mental health stressors like peer harassment, bullying, and family rejection, specific problems that are addressed elsewhere in this issue (see Mark L. Hatzenbuehler and John E. Pachankis’ article, “ Stigma and Minority Stress as Social Determinants of Health Among LGBT Youth: Research Evidence and Clinical Implications ”; Valerie A. Earnshaw and colleagues’ article, “ LGBT Youth and Bullying ”; and Sabra L. Katz-Wise and colleagues’ article, “ LGBT Youth and Family Acceptance ,” in this issue). The mental health needs of youth diagnosed with gender dysphoria, who may be growing up to be transgender adults, remain relatively understudied, particularly in the United States; however, this group of young people also appears at heightened risk for mental health problems, including anxiety, peer and behavior problems, anger and depression, suicidality, and risk-taking behaviors. It is also known that transgender adults are at increased risk for mental health problems like depression, anxiety, or substance abuse. Fortunately, early appropriate intervention appears to decrease subsequent risk.
As social tolerance increases and LGBT people become more visible, youth may recognize and possibly reveal LGBT feelings or identities in greater numbers and at younger ages. As primary care clinicians may encounter these youth, it is important to know how to meet their needs in primary pediatric health settings. Pediatricians who have the first contact also may have an opportunity to recognize and assess any specific mental health needs. Therefore, pediatric clinical competence includes assessing developmental domains of sexuality and gender of all youth, including nonheterosexual orientation, nonconformity in gender expression, and gender-variant identity and any related needs. This includes assessing youths’ mental health needs, including their vulnerability and resilience to LGBT-related stigma. As youth may be hesitant to disclose their concerns, it is important that pediatric providers be familiar with and able to intervene appropriately for sexuality, gender-related, and mental health issues.
This article discusses how basic principles of mental health care for LGBT youth can be integrated into routine pediatric care, illustrating ways of doing so with hypothetical case vignettes. In doing so, it assumes basic familiarity with fundamental concepts and skills related to pediatric mental health, and provides clinical guidance in applying mental health practice principles for the LGBT population in pediatric primary care settings.
Introduction
Mental health problems are highly prevalent in youth and are a significant cause of morbidity and mortality. For example, among adolescents and young adults in the United States, suicide is the third leading cause of mortality from age 10 to 14 years, and the second from age 15 to 24 years. If left unaddressed, mental health problems like depression, anxiety, disruptive behavior, and learning problems can become chronic and cause serious morbidity; however, these can be significantly ameliorated by appropriate mental health interventions. In addition to their inherent morbidity and mortality, psychiatric illnesses also may increase physical health risk behavior; for example, substance abuse (see Romulo Alcalde Aromin Jr’s article, “ Substance Abuse Prevention, Assessment and Treatment for LGBT Youth ,” in this issue) is associated with increased sexual risk behavior and exposure to sexually transmitted infections (STIs). Therefore, these are very important problems for pediatricians to know about, recognize, and address.
Most youth with psychiatric diagnoses do not receive formal mental health treatment; as a result, mental health problems in children and adolescents are often encountered first by pediatricians. The delay from the initial onset of symptoms until the start of mental health treatment can be years. According to the Agency for Healthcare Research and Quality (2009), children’s mental health disorders are among the top 5 most-costly medical conditions, costing the United States $8.9 billion annually. Therefore, pediatric primary care providers and other pediatric clinicians play a key role in detecting, assessing, and addressing youths’ mental health needs.
Lesbian, gay, bisexual, or transgender (LGBT) youth have the same pediatric and developmental needs as the general population, as well as certain LGBT-specific health and mental health needs. The ability to intervene appropriately when mental health problems exist, an important pediatric clinical competence in general, may be especially salient for youth who are or might be on a developmental path toward being LGBT. Although most lesbian, gay, and bisexual (LGB) youth are free from mental illness, a minority develops a psychiatric illness or has other mental health needs, like all youth.
The rates at which LGB youth experience certain mental illnesses, such as depression, anxiety, and substance abuse, are increased in comparison with the general population. For example, they are at twofold to fivefold risk for suicidality. This increase appears to be related to increased exposure to mental health stressors like peer harassment, bullying, and family rejection, specific problems that are addressed elsewhere in this issue (see Mark L. Hatzenbuehler and John E. Pachankis’ article, “ Stigma and Minority Stress as Social Determinants of Health Among LGBT Youth: Research Evidence and Clinical Implications ”; Valerie A. Earnshaw and colleagues’ article, “ LGBT Youth and Bullying ”; and Sabra L. Katz-Wise and colleagues’ article, “ LGBT Youth and Family Acceptance ,” in this issue). The mental health needs of youth diagnosed with gender dysphoria, who may be growing up to be transgender adults, remain relatively understudied, particularly in the United States; however, this group of young people also appears at heightened risk for mental health problems, including anxiety, peer and behavior problems, anger and depression, suicidality, and risk-taking behaviors. It is also known that transgender adults are at increased risk for mental health problems like depression, anxiety, or substance abuse. Fortunately, early appropriate intervention appears to decrease subsequent risk.
As social tolerance increases and LGBT people become more visible, youth may recognize and possibly reveal LGBT feelings or identities in greater numbers and at younger ages. As primary care clinicians may encounter these youth, it is important to know how to meet their needs in primary pediatric health settings. Pediatricians who have the first contact also may have an opportunity to recognize and assess any specific mental health needs. Therefore, pediatric clinical competence includes assessing developmental domains of sexuality and gender of all youth, including nonheterosexual orientation, nonconformity in gender expression, and gender-variant identity and any related needs. This includes assessing youths’ mental health needs, including their vulnerability and resilience to LGBT-related stigma. As youth may be hesitant to disclose their concerns, it is important that pediatric providers be familiar with and able to intervene appropriately for sexuality, gender-related, and mental health issues.
This article discusses how basic principles of mental health care for LGBT youth can be integrated into routine pediatric care, illustrating ways of doing so with hypothetical case vignettes. In doing so, it assumes basic familiarity with fundamental concepts and skills related to pediatric mental health, and provides clinical guidance in applying mental health practice principles for the LGBT population in pediatric primary care settings.
The basics: lesbian, gay, bisexual, or transgender youth development and mental health concepts in pediatric practice
The Pediatrician’s Perspective on Development of Sexual Orientation, Gender Expression, and Gender Identity
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Sexual orientation, gender expression, and gender identity are distinct developmental domains that pediatricians should know and be able to differentiate in youth.
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Forming a sexual orientation and/or a gender identity different from others’ expectations and contemplating “coming out” are frequent, unique developmental experiences of LGBT youth.
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A homosexual or bisexual orientation involves attraction to the same sex and can involve emotional and/or erotic feelings, sexual behavior, and/or a youth’s identity. These dimensions of sexual orientation may develop over time and may or may not be congruent, sometimes reflecting emotional conflict.
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Gender expression refers to gender-related behavior in areas such as toy preference, rough-and-tumble play, use of styles, and mannerisms. Some youth display gender nonconformity , or variation from group norms, in their expression of gender-related behavior.
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Gender identity refers to an individual’s personal sense of gender. In some youth it differs from the sex that was recognized and the gender assigned by others at birth. Gender dysphoria is distress due to discordance between assigned sex/gender and gender identity, and is distinct from distress due to stigma; each requires appropriate intervention.
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Nonheterosexual orientation, gender nonconformity, and gender dysphoria can occur together, but are distinct phenomena and frequently do not occur together. For example, being gay, lesbian or bisexual, sometimes accompanied by a degree of gender nonconformity in youth, is different from being transgender, which may benefit from specific interventions (see Annelou L.C. de Vries’ article, “ What the Primary Care Pediatrician Needs to Know About Gender Variance in Children and Adolescents ,” in this issue).
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Each youth can have a distinctive profile of vulnerability and resilience to LGBT-related stress.
Sexual and gender development begins in youth. Gender identity, gender role behavior, and sexual orientation are 3 distinct but interconnected domains of development. In the course of development, youth may exhibit variation from their peers and others’ expectations in 1, 2, or all 3 of these domains. Although these may constitute normal variations in development, they may diverge from peer, family, and societal expectations and values, and may elicit negative reactions. Youth who fear being rejected by others may agonize over revealing sexual or gender-related feelings or experiences. This can lead to hiding of (being “in the closet” about) experiences such as same-sex sexual or romantic feelings, nonconformity in gender role behavior, or gender dysphoria, and struggling with revealing these to others (“coming out” to others). These are hallmark concerns that are common among and unique to the development of LGBT youth.
Pediatric clinicians may not be aware that they are caring for an LGBT youth, since some may be not prepared to discuss their sexual and gender development. However, approaching all youth tactfully and confidentially with an awareness that they could be LGBT provides the appropriate guidance, assessment and services if needed. They should monitor how youth are coping with any stresses related to these areas of development, support them, and provide help for any mental health problems that might emerge. In many cases, to preserve the clinical alliance, a clinician may choose to respect a youth’s reticence; however, in other situations, an urgent mental health problem may require a pediatric practitioner to take initiative in exploring and addressing an issue.
It is important that pediatric caregivers realize that any youth may be or become lesbian, gay, bisexual or transgender, whether or not they are perceived or have identified themselves as such. Clinicians should be accepting of youth with any expression or disclosure of sexual orientation or gender identity, and foster a clinical relationship characterized by safety and professional support for healthy development, whatever the ultimate sexual orientation or gender identity. They should encourage good peer relations and family connectedness whenever possible, and support resilience and adaptive coping with stress. These principles are well suited to supporting development and providing anticipatory guidance and other well-established models of care.
Sexual Orientation
Human beings differ with regard to their degree of emotional and sexual attraction to those of the opposite or same sex. Most people find that they are predominantly attracted to those of the opposite sex. However, a substantial minority are attracted sexually and emotionally to both or the same sex to a significant or exclusive degree, and thus has a gay, lesbian, or bisexual orientation. These are normal variations in the patterns of human sexual orientation that are frequently first recognized in youth. They may influence the individual’s feelings of attraction, patterns of arousal, fantasies, masturbatory or interpersonal sexual behavior, and/or identity. For some, patterns of attraction may change over time, whereas for others they are enduring. Identity may involve a youth’s private sense of self, which may be concealed or revealed to others to various degrees over time. These dimensions of sexual orientation may coincide in some individuals, but may not in others.
Most LGB youth gradually discover their sexual orientation over time. As this occurs, some youth struggle with shame, guilt, and the belief that their sexual orientation is unacceptable to themselves and/or others. This may be a source of distress that, in susceptible individuals, may increase the risk of mental health problems. This may be related to negative attitudes or reactions of peers, family, or others in society. Many youth with LGB attractions and/or behavior do not have an LGB identity. This may reflect a conflict over sexual orientation in some individuals. It is important that pediatricians monitor for mental health problems that can arise in this context, be aware of their relation to the unique developmental struggles of LGB youth, and intervene appropriately and sensitively.
Gender-Related Behavior and Gender Nonconformity
It is important that pediatric clinicians understand the phenomenon of gender nonconformity. As described in the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter on LGBT youth, most children display patterns of gender-typed behavior in such areas as toy preferences and degree of inclination toward rough-and-tumble play, dress, mannerisms, or playmate sex preferences; this is gender-related behavior . In a given youth, these may approximate group norms to varying degrees. Some youth display patterns that are atypical for their gender, or gender nonconforming . Although this can occur to varying degrees, in some youth, nonconformity in gender behavior expression is more significant and/or consistent than in others.
Pediatric clinicians should know that childhood gender nonconformity is sometimes (although not always) associated with nonheterosexual orientation in adolescence. This appears to be especially so for boys, but also sometimes for girls. Although such gender nonconformity is not an illness and not always associated with growing up LGB or T, pediatricians should know about it and its partial association with sexual orientation and gender identity variance, because it can make youth feel different from peers from childhood on and influence how they communicate later with others about their sexual orientation and gender identity. Gender nonconformity also can be a risk factor for adverse phenomena like peer harassment, bullying, and family rejection. These problems may place susceptible youth at risk for adverse mental health outcomes like depression, anxiety, and suicidality (see Mark L. Hatzenbuehler and John E. Pachankis’ article, “ Stigma and Minority Stress as Social Determinants of Health Among LGBT Youth: Research Evidence and Clinical Implications ”; Valerie A. Earnshaw and colleagues’ article, “ LGBT Youth and Bullying ”; and Sabra L. Katz-Wise and colleagues’ article, “ LGBT Youth and Family Acceptance ,” in this issue). Fortunately, pediatric clinicians can intervene in ways described in these articles to decrease their likelihood.
Gender Identity and Gender Dysphoria
Pediatricians should understand gender identity and gender dysphoria , a unique phenomena that may benefit from specific pediatric interventions. In contrast with gender-related behavior, gender refers to a person’s social (and usually legal) assignment as female or male in a society with a binary gender system, or as female, male, or an alternate category in a society that has them (for example, India recently established legal recognition of hijras ). Gender is usually recognized at birth based on the appearance of the external genitalia corresponding with the genetic makeup and its phenotypic expression. Gender identity refers to an individual’s sense of gender. Some youth discover that their gender identity is different from the one assigned, or that they are between genders, identify with both genders, feel gender neutral, are “gender queer,” or “expansive” – terms meaning not conventionally categorizable that are used with increasing frequency by youth diagnosed with gender dysphoria.
Gender identity and gender expression are different. Gender dysphoria frequently occurs in conjunction with marked behavioral gender nonconformity, but also can occur without gender-nonconforming behavior in some people. In contrast with gender nonconformity alone, gender dysphoria can benefit from specific interventions (see Annelou L.C. de Vries and colleagues’ article, “ What the Primary Care Pediatrician Needs to Know About Gender Variance in Children and Adolescents ,” in this issue). The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) defines gender dysphoria as distress about a gender identity that differs from the individual’s socially assigned sex/gender. By definition, gender dysphoria is distress about the discordance between a youth’s gender identity and sex assigned at birth. However, stigma, sometimes enacted as harassment, bullying, or family rejection, can be another important source of distress.
Clinical samples with limited follow-up have found prepubertal gender dysphoria to be transient in some youth and persistent in others. Predictors of persistence in clinical cohorts include a greater intensity of gender dysphoria and meeting criteria for a DSM diagnosis; a cognitive or affective cross-gender identification (that is, saying “I am” or “I feel like” rather than “I wish I were the other sex”); having a younger age of presentation; being a birth assigned male; and having gone through an early social role transition (especially in birth assigned boys).
When gender dysphoria is present in adolescence, it usually remains a stable trait. Although adolescents can grow up to have any sexual orientation, studies limited to specialty clinic cohorts have found children diagnosed with gender dysphoria to develop nonheterosexual orientations more frequently than most children. Further research, including population samples and long-term follow-up studies, is needed to determine how these findings apply to youth seen by general pediatricians and to guide best practices.
Distinguishing Gender Nonconformity and Gender Dysphoria
A youth’s feelings of gender dysphoria may first come to a primary care clinician’s attention in a variety of ways. These may include issues or concerns raised directly by the youth, parents, or others. It is important that clinicians understand that gender-nonconforming behavior and gender dysphoria are different, albeit sometimes co-occurring, phenomena. In some youth, gender dysphoria may be suggested by significant, persistent gender-nonconforming behavior, whereas in others, gender-nonconforming behavior occurs without gender dysphoria. Distinguishing youth with gender-nonconforming behavior alone from those who may be experiencing gender dysphoria can be clinically challenging; for example, in youth not yet ready or developmentally able to verbalize their thoughts and feelings, who have comorbid mental health issues that interfere with doing so, or who are experiencing uncertainty about their identity for other reasons. Nevertheless, making this distinction is important, because youth diagnosed with gender dysphoria may benefit from gender treatments (see Annelou L.C. de Vries and colleagues’ article, “ What the Primary Care Pediatrician Needs to Know About Gender Variance in Children and Adolescents ,” in this issue). However, not all behaviorally gender-nonconforming youth experience gender dysphoria. Many or most gender-nonconforming youth who pediatricians may see will not experience gender dysphoria, including many nontransgender youth growing up gay, lesbian, or bisexual. In contrast to transgender youth, some non-transgender gay, lesbian, or bisexual youth may fear being regarded as not belonging to their assigned birth gender. For them, gender-affirming care would not involve the same treatments described for those diagnosed with gender dysphoria described in Annelou L.C. de Vries and colleagues’ article, “ What the Primary Care Pediatrician Needs to Know About Gender Variance in Children and Adolescents ,” in this issue.
To assist with accurate assessment and appropriate interventions, pediatric clinicians may find it helpful to obtain consultation from developmental or mental health specialists with clinical competence in sexual orientation and gender. These may be available locally, by consulting published guidelines and tools for assessment, or through national organizations such as the AACAP ( www.aacap.org ), the National LGBT Health Education Center ( www.lgbthealtheducation.org ), the Substance Abuse and Mental Health Services Administration (SAMHSA)’s National Suicide Resources ( www.suicidepreventionlifeline.org ), The Trevor Project ( www.thetrevorproject.org/pages/get-help-now#tc ), or the Crisis Text Line ( www.crisistextline.org/textline/ ). It is important for pediatric care providers to allow children and adolescents to discover and reveal themselves over time, to consider both immediate and long-term needs in the context of current research, to promote well-being and avoid harm, and resist premature conclusions about anyone’s future developmental endpoints.
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