Key points

Video content accompanies this article at http://www.pediatric.theclinics.com .

Introduction

Why talk to adolescents about sexual matters, including gender?

• •
  

  Sexuality, sex, and relationships are integral parts of adolescent health and development.

  
  
• •
  

  Gender is part of every patient and should be affirmed as part of patient-centered primary care.

  
  
• •
  

  Lesbian, gay, bisexual, transgender (LGBT) youth face physical, mental, and emotional health disparities compared with their heterosexual peers.

Sexuality is an integral part of adolescent health and development and should be assessed routinely at every patient visit. Sexuality development lies on a continuum along which young people move in the context of relationships and is a healthy, natural part of life. Adolescents engage in relationships that may include a variety of sexual activities, and pediatricians play a pivotal role in supporting youth to actively participate in decision making around safe, positive sexual behaviors and practices, including abstinence if that is their choice.

Expanding social relationships and friendships is part of adolescent development. Sexual activity may be a natural and healthy outgrowth of some relationships. Healthy relationships include elements of partner support, honesty, kindness, openness, encouragement, and respect of individual space and time. In contrast, unhealthy relationships occur if a partner is overly jealous, demanding, controlling, or shaming, or if he or she physically and/or sexually hurts, humiliates, or threatens the other person.

According to the 2015 Youth Risk Behavior Surveillance (YRBS), 41% of high school students report having sexual intercourse and 30% report having sexual intercourse with at least one person during the 3 months before the survey. Some of these encounters were consensual, whereas others were not. YRBS found that 10% of high school students reported that the person whom they were dating deliberately hurt them physically; 11% said that they were forced to perform sexual acts that they did not want to do, and 7% said that they were physically forced to have sexual intercourse.

Adolescent relationship abuse is common and can take many forms, including emotional/mental abuse, physical abuse, sexual abuse, reproductive coercion, cyber abuse, harassment, isolation, threats, and controlling jealousy (see Elizabeth Miller’s article, “ Prevention and Intervention for Dating Violence in Adolescents ,” in this issue).

Pediatricians and other health care providers have an essential role to assess and provide routine education about healthy relationships and identify young people experiencing relationship abuse and intimate partner violence (IPV). Simply acknowledging relationship abuse, validating feelings, and providing support without judgment can create trusting relationships with patients so they feel comfortable and safe discussing these topics.

Pediatricians are uniquely positioned to talk to adolescents about sex, sexuality, and relationships as essential caregivers in their young lives. Even before adolescence begins, pediatricians have both the opportunity and the responsibility to initiate conversations about sexual matters ( Table 1 ). Health care provider discomfort and lack of formal medical training for primary care providers on how to talk to adolescents about sexuality are 2 barriers to having these conversations. Fortunately, the more one practices initiating and having these discussions, the more comfortable one becomes.

Starting these conversations early, with confidentiality pre-established, will ultimately equip adolescent patients with the knowledge and skills to make healthy decisions about their own sexual lives. Furthermore, building trust and rapport with adolescent patients helps them feel more comfortable, better prepared, and empowered to speak with future health care providers about their sexuality and sexual experiences as they enter young adulthood and beyond.

Major medical organizations, including the American Academy of Pediatrics (AAP), the American Medical Association, and the Society for Adolescent Health and Medicine, recommend that health care providers counsel and educate all adolescents about sexual matters and sexual decision making. The 2016 AAP Clinical Report on Sexuality Education for Children and Adolescents provides specific clinical guidelines for pediatricians to both initiate conversations about sex and sexuality and discuss topics, including confidentiality, gender, sexual identity, healthy relationships and IPV, sexual pleasure, empowerment, and responsibility.

Unfortunately, studies show that pediatricians do not routinely initiate talks about sexual matters, and when the topic is raised, discussions are brief and incomplete. One observational study found that among 253 adolescents surveyed, one-third reported no discussion of sexual issues at annual visits, and when the discussion did occur, it only lasted 36 seconds. Another study of AAP members found that although most pediatricians discussed sexual activity at preventive care visits, they rarely or never discussed sexual identity/homosexuality. This finding is especially troubling when LGBT youth face numerous physical, mental, and emotional health disparities compared with heterosexual youth.

Thirty to 40% of LGBT youth in the United States are homeless, and sexual minority homeless youth have increased lifetime sexual partners, higher rates of sexually transmitted infections (STIs), and younger ages of sexual initiation. A nationally representative sample found that almost one-quarter of adolescents in same-sex relationships reported some type of IPV and those who identify as transgender experience higher rates of IPV than both heterosexual and other LGB communities. Findings from a nationwide school survey found that LGBT youth reported increased risk of bullying and physical/verbal harassment in the past year due to sexual orientation. Bisexual and lesbian female adolescents are at greater risk for earlier age at heterosexual debut, more sexual partners, forced sex by male partner, unintended pregnancy, and STIs. Adolescents who identify as Lesbian, Gay or Bisexual also report higher rates of depression, anxiety, suicidal thoughts, and self-harm.

Although many LGBT youth are disproportionately affected by risk-taking behaviors, most grow up healthy and lead happy, productive lives. For LGBT youth, adolescence is a developmental phase in which many physical, emotional, social, and sexual changes take place, similarly to heterosexual youth. However, for many sexual minority youth, these changes are more challenging and difficult because of family disapproval, societal and internalized homophobia, and discriminatory treatment in health care settings. To overcome stress created by stigmatization, many LGBT youth develop and possess remarkable strength and self-determination.

How can pediatricians help mitigate lesbian, gay, bisexual, transgender youth health disparities?

• •
  

  Initiate discussions about gender and sexual identity

  
  
• •
  

  Use inclusive, nonjudgmental language to normalize diversities in identities, attractions, and behaviors

  
  
• •
  

  Provide affirming support and resources as needed

When asked questions about sexual orientation and gender identity (SOGI) by their providers, most heterosexual and LGBT patients in primary care settings answered them, said they would respond to such questions in the future, and expressed positive support for the importance of asking these questions. Ideally, pediatricians and other health care providers should ask all adolescent patients standardized SOGI questions as part of routine care. Most youth find the questions both acceptable and important for their medical provider to know. Furthermore, most LGBT respondents said the survey questions allowed them to accurately document their SOGI, which allows providers to make a better assessment of the patient’s health and potential risk factors.

In order to have inclusive conversations with all adolescent patients, it is best to use gender-neutral language and avoid assumptions about gender identity, sexual attractions, and sexual orientation identity. One study examining language used by physicians talking with adolescents about sexuality found that inclusive talk rarely occurred (3.3%), while noninclusive language was predominant. Health care providers in these primary care clinics often assumed heterosexuality and heterosexual sexual behaviors or more indirectly framed the talk as heterosexual. Sexual minority adolescents are prone to feeling shame and isolation when health care providers fail to use inclusive language or make assumptions about their sexuality. In qualitative interviews, those participants who identified as bisexual, gay, or pansexual reported that being asked, “How is your girlfriend/boyfriend?” as if they were heterosexual, made them feel unaccepted by their health care provider.

Introduction

Why talk to adolescents about sexual matters, including gender?

• •
  

  Sexuality, sex, and relationships are integral parts of adolescent health and development.

  
  
• •
  

  Gender is part of every patient and should be affirmed as part of patient-centered primary care.

  
  
• •
  

  Lesbian, gay, bisexual, transgender (LGBT) youth face physical, mental, and emotional health disparities compared with their heterosexual peers.

Sexuality is an integral part of adolescent health and development and should be assessed routinely at every patient visit. Sexuality development lies on a continuum along which young people move in the context of relationships and is a healthy, natural part of life. Adolescents engage in relationships that may include a variety of sexual activities, and pediatricians play a pivotal role in supporting youth to actively participate in decision making around safe, positive sexual behaviors and practices, including abstinence if that is their choice.

Expanding social relationships and friendships is part of adolescent development. Sexual activity may be a natural and healthy outgrowth of some relationships. Healthy relationships include elements of partner support, honesty, kindness, openness, encouragement, and respect of individual space and time. In contrast, unhealthy relationships occur if a partner is overly jealous, demanding, controlling, or shaming, or if he or she physically and/or sexually hurts, humiliates, or threatens the other person.

According to the 2015 Youth Risk Behavior Surveillance (YRBS), 41% of high school students report having sexual intercourse and 30% report having sexual intercourse with at least one person during the 3 months before the survey. Some of these encounters were consensual, whereas others were not. YRBS found that 10% of high school students reported that the person whom they were dating deliberately hurt them physically; 11% said that they were forced to perform sexual acts that they did not want to do, and 7% said that they were physically forced to have sexual intercourse.

Adolescent relationship abuse is common and can take many forms, including emotional/mental abuse, physical abuse, sexual abuse, reproductive coercion, cyber abuse, harassment, isolation, threats, and controlling jealousy (see Elizabeth Miller’s article, “ Prevention and Intervention for Dating Violence in Adolescents ,” in this issue).

Pediatricians and other health care providers have an essential role to assess and provide routine education about healthy relationships and identify young people experiencing relationship abuse and intimate partner violence (IPV). Simply acknowledging relationship abuse, validating feelings, and providing support without judgment can create trusting relationships with patients so they feel comfortable and safe discussing these topics.

Pediatricians are uniquely positioned to talk to adolescents about sex, sexuality, and relationships as essential caregivers in their young lives. Even before adolescence begins, pediatricians have both the opportunity and the responsibility to initiate conversations about sexual matters ( Table 1 ). Health care provider discomfort and lack of formal medical training for primary care providers on how to talk to adolescents about sexuality are 2 barriers to having these conversations. Fortunately, the more one practices initiating and having these discussions, the more comfortable one becomes.

Starting these conversations early, with confidentiality pre-established, will ultimately equip adolescent patients with the knowledge and skills to make healthy decisions about their own sexual lives. Furthermore, building trust and rapport with adolescent patients helps them feel more comfortable, better prepared, and empowered to speak with future health care providers about their sexuality and sexual experiences as they enter young adulthood and beyond.

Major medical organizations, including the American Academy of Pediatrics (AAP), the American Medical Association, and the Society for Adolescent Health and Medicine, recommend that health care providers counsel and educate all adolescents about sexual matters and sexual decision making. The 2016 AAP Clinical Report on Sexuality Education for Children and Adolescents provides specific clinical guidelines for pediatricians to both initiate conversations about sex and sexuality and discuss topics, including confidentiality, gender, sexual identity, healthy relationships and IPV, sexual pleasure, empowerment, and responsibility.

Unfortunately, studies show that pediatricians do not routinely initiate talks about sexual matters, and when the topic is raised, discussions are brief and incomplete. One observational study found that among 253 adolescents surveyed, one-third reported no discussion of sexual issues at annual visits, and when the discussion did occur, it only lasted 36 seconds. Another study of AAP members found that although most pediatricians discussed sexual activity at preventive care visits, they rarely or never discussed sexual identity/homosexuality. This finding is especially troubling when LGBT youth face numerous physical, mental, and emotional health disparities compared with heterosexual youth.

Thirty to 40% of LGBT youth in the United States are homeless, and sexual minority homeless youth have increased lifetime sexual partners, higher rates of sexually transmitted infections (STIs), and younger ages of sexual initiation. A nationally representative sample found that almost one-quarter of adolescents in same-sex relationships reported some type of IPV and those who identify as transgender experience higher rates of IPV than both heterosexual and other LGB communities. Findings from a nationwide school survey found that LGBT youth reported increased risk of bullying and physical/verbal harassment in the past year due to sexual orientation. Bisexual and lesbian female adolescents are at greater risk for earlier age at heterosexual debut, more sexual partners, forced sex by male partner, unintended pregnancy, and STIs. Adolescents who identify as Lesbian, Gay or Bisexual also report higher rates of depression, anxiety, suicidal thoughts, and self-harm.

Although many LGBT youth are disproportionately affected by risk-taking behaviors, most grow up healthy and lead happy, productive lives. For LGBT youth, adolescence is a developmental phase in which many physical, emotional, social, and sexual changes take place, similarly to heterosexual youth. However, for many sexual minority youth, these changes are more challenging and difficult because of family disapproval, societal and internalized homophobia, and discriminatory treatment in health care settings. To overcome stress created by stigmatization, many LGBT youth develop and possess remarkable strength and self-determination.

How can pediatricians help mitigate lesbian, gay, bisexual, transgender youth health disparities?

• •
  

  Initiate discussions about gender and sexual identity

  
  
• •
  

  Use inclusive, nonjudgmental language to normalize diversities in identities, attractions, and behaviors

  
  
• •
  

  Provide affirming support and resources as needed

When asked questions about sexual orientation and gender identity (SOGI) by their providers, most heterosexual and LGBT patients in primary care settings answered them, said they would respond to such questions in the future, and expressed positive support for the importance of asking these questions. Ideally, pediatricians and other health care providers should ask all adolescent patients standardized SOGI questions as part of routine care. Most youth find the questions both acceptable and important for their medical provider to know. Furthermore, most LGBT respondents said the survey questions allowed them to accurately document their SOGI, which allows providers to make a better assessment of the patient’s health and potential risk factors.

In order to have inclusive conversations with all adolescent patients, it is best to use gender-neutral language and avoid assumptions about gender identity, sexual attractions, and sexual orientation identity. One study examining language used by physicians talking with adolescents about sexuality found that inclusive talk rarely occurred (3.3%), while noninclusive language was predominant. Health care providers in these primary care clinics often assumed heterosexuality and heterosexual sexual behaviors or more indirectly framed the talk as heterosexual. Sexual minority adolescents are prone to feeling shame and isolation when health care providers fail to use inclusive language or make assumptions about their sexuality. In qualitative interviews, those participants who identified as bisexual, gay, or pansexual reported that being asked, “How is your girlfriend/boyfriend?” as if they were heterosexual, made them feel unaccepted by their health care provider.