I. Recognition of sexual orientation and gender identification. Before adolescents are able to self-identify with any form of sexual orientation, they often question what their feelings, fantasies, and behaviors mean, and if they are transient or an intrinsic part of themselves. Rather than relying upon a stringent categorization of individuals as heterosexual, homosexual, or bisexual, sexual orientation should be viewed as a continuum ranging from absolute heterosexuality to absolute homosexuality. Adolescents have come to recognize and acknowledge their sexual orientation at younger ages recently, presumably due to the increased visibility and social acceptance of the diversity of sexual orientation and sexual expression. Given appropriate information and support, individuals generally will resolve uncertainty about sexual orientation by late adolescence through self-exploration of feelings, fantasies, and experiences. Children may also be coming to recognize discomfort with their anatomic sex and explore the implications of a transgender identity at younger ages than was previously believed.

III. Epidemiology. Evidence suggests that homosexuality has existed in all societies and cultures, but the stigma associated with it is so powerful that it has remained largely unmentionable and secret. Most of the published information is based on reports from middleclass, well-educated, Caucasian populations, as the stigma of homosexuality is even greater among people of color, certain religions, and developing nations.

V. Stages in the formation of a homosexual identity. A typical progression in stages of understanding and acceptance of sexual orientation was developed by Richard Troiden in relation to homosexual males, and may differ for females.

Stage I: sensitization. The prepubertal stage is not within the realm of sexuality, but rather refers to generalized feelings of being different from same-sex peers. This is recognized largely by gender-neutral or gender-atypical interests and behaviors.

Stage II: identity confusion. The realization in early adolescence that his/her feelings and/or behaviors may be identified as homosexual/bisexual often surprises the youth and clashes with previously held self-images. This results in confusion and uncertainty about sexual identity. Youths may respond to identity confusion in one of several ways:

Stage III: identity assumption. Begins with self-definition as homosexual and may include regular association with other homosexual teens, sexual experimentation, and embarking on the lengthy and complex process of sharing his or her identity with others (“coming out”). Adolescents usually confide in a sibling, friend, or teacher before informing their parents or professionals.

Stage IV: commitment. Usually marked by self-acceptance, emotional intimacy, and a clear recognition of sexual orientation. Commitment occurs when the youth’s homosexual identity is internalized and integrated. This stage is generally reached during adulthood.

VI. Psychosocial and medical risks. Although homosexual youth have many of the same medical concerns and needs as heterosexual teenagers, some are also at increased risk for a variety of psychosocial and medical problems, based on sexual activity and the experience of growing up in a society without widespread acceptance of sexual minorities. The increased risk is not inherent to sexual orientation, as some gay, lesbian, bisexual, and transgender (GLBT) youth navigate this transition without apparent difficulty. However, social ostracism, stigma, stress, and lack of social support and acceptance may result in mental illness, risky behaviors, and increased healthcare needs. The challenge for pediatric clinicians is to direct youth and their parents to appropriate information and social supports and to be alert to special needs expressed by those GLBT youth who are at increased risk for negative outcomes.

Heightened risks exist for sexually active GLBT youth for both medical and psychosocial problems (see Table 46-1).