An 18-year-old female came to clinic for a health supervision examination prior to starting college in a distant city.
During the interview, the physician asked if she had “???been sexually active now or in the past with boys, girls, men or women?”The women paused, took a deep breath and quietly said yes.
The physician then inquired what she was saying yes to.
The woman confided that she was in a lesbian relationship for the past 6 months.
During the discussion, she said that she “always knew that I was a lesbian” and that she could not remember ever being sexually attracted to men or boys.
Her current relationship was mutually monogamous as far as she knew and she trusted her partner.
They both had been seen at a local reproductive health clinic for routine gynecological care and testing for sexually transmitted infections and human immunodeficiency virus before beginning their sexual relationship.
They did not use condoms or dental dams during sexual encounters.
When asked who knew about her sexual orientation, she stated that a few trusted, same-aged friends, but no family members.
She denied any harassment or violence, depression, or suicidal ideation.
The past medical history,
and review of systems were non-contributory.
The pertinent physical exam showed a quiet female with normal vital signs and growth parameters.
Her physical examination was normal.
The diagnosis of a healthy female who had disclosed lesbian homosexual orientation was made.
At this time, she had no plans to disclose her sexual orientation to her family and a general discussion of possibly how to do so was discussed.
The physician utilized the room’s computer to access local LGBTQ resources (i.e. lesbian, gay, bisexual, transgender and questioning people) at her college’s health center and community.
This information was printed after the woman stated she had a safe place to keep the information at home and felt comfortable taking it with her.
In addition to the other anticipatory guidance and health care provided, the physician reiterated that she could confidentially telephone to the office if she had questions.
The physician did encourage electronic mail correspondence if the issue was not sensitive, but not for any sensitive information particularly about her sexual orientation.
Sexuality and social and family functioning and relationships are important components of comprehensive medical care and should be discussed at every health supervision for children and adolescents.
Homosexuality in children and/or their parents is common and pediatric health care providers should be aware of the specific needs of each child, adolescent and family.
Some sexual definitions include:
- Sexual orientation is the sexual desire for a particular gender, or an intensive internal physiological desire for a particular gender. Homosexual, heterosexual and bisexual are examples of sexual orientation.
Sexual orientation is stable over time, and is resistant to conscious control. It is not a choice.
- Sexual behavior are physical behaviors that are conscious choices. These behaviors are usually motor, (e.g. “he plays with dolls”, “she’s so macho”) and may or may not change over time.
- Gender identity is a person’s self concept of their own gender and includes an integration of the person’s biological sex, gender role expression and sexual orientation.
- Gay refers to a male whose primary, loving, sexual and/or intimate relationships are with men.
- Lesbian refers to a woman whose primary, loving, sexual and/or intimate relationships are with women.
- Bisexual refers to a person who is sexually, emotionally and/or intimately attracted to either sex but not necessarily at the same time.
- Transgender is a general term for crossing gender lines. It may refer to persons who are transsexuals or transvestites/cross-dressers.
- Questioning refers to individual who is not sure about their sexual orientation.
- LGBTQ (lesbian, gay, bisexual, transgender and questioning people) terminology describes sexual orientation, not sexual behavior.
It is very common for adolescents and adults to engage in sexual behaviors that others may define as homosexual in nature.
Since these are sexual behaviors, they are subject to conscious choice and can change over time.
Many of these “experimenting” individuals would identify themselves as having a heterosexual orientation.
Individuals may also consider themselves heterosexual but may engage in homosexual sexual behaviors to gain money and /or favors. One example is prostitution.
This confusion between sexual orientation and sexual behavior can lead to imprecise/inaccurate communication and even research.
In a recent study in The Lancet of global sexual behavior, it appears that there was significant underreporting of homosexual sexual behavior in persons who report themselves as heterosexuals.
This is particularly true of men who are married to women.
Persons who are homosexual may experience a variety of medical or social problems that can affect their health.
- Mental health – including isolation, depression, suicide, poor self-esteem, fear
- Sexually transmitted infections and pregnancy – especially Gonorrhea, Hepatitis B and C, Human Immunodeficiency Virus, Syphilis.
- Social and legal – difficulties identifying where and how to socialize, discrimination in employment, housing, public accommodations, public events
- Substance abuse
- Violence – including bullying, harassment, sexual violence/abuse, physical violence/abuse or death
It is not uncommon for adolescents to “experiment” with different sexual behaviors and therefore even those persons who have a homosexual orientation should be counseled about safe-sex practices and contraception options.
In addition to assuring and maintaining information confidentiality with all patients, using gender-neutral questions on health questionnaires and during the health interview may allow youth and their families to give more accurate information.
For example, health questionnaires that ask for information about a mother and a father, may not gather all the pertinent information in a 2-adult gay/lesbian household or a foster care family.
Using a generic term such as “Guardian” as the header with a follow-up question about the “Relationship to Patient” offers more flexibility.
Some people recommend to have at least 4 spaces on the health form for “Guardian” because of the high rate of divorce, kinship care, and foster and adoptive care.
The following are some suggestions for gender-neutral sexual questions. The terms men and women can be substituted or added as is appropriate to the terms boys and girls used below:
- Many of my patients are dating other boys, girls or both. Are you interested in dating?
- Have you ever dated or gone out with someone? Are you dating or going out with someone now?
- Have you ever been attracted to girls, boys or both? Are you especially attracted to any boys or girls?
- Many boys and girls are sexual with other boys or girls. They may kiss, hug, pet or have oral, anal or vaginal intercourse. Have you every had any sexual experiences like these or other experiences with girls or boys or both?
- What kind of sexual experiences have you had? Did you have them with boys? Did you have them with girls? Did you have them with both?
- What kind of protection did you and your partner(s) use for pregnancy and sexually transmitted diseases?
- Do you have any concerns about your sexual feelings or the sexual things you have been doing or want to do in the future?
- Have you ever talked with someone about your sexual feelings?
- Do you consider yourself to be gay/lesbian, bisexual or straight (heterosexual)? Are you asking/questioning what you want to call yourself?
Some adolescents may be reticent to disclose their sexual behaviors or use different terminology to describe them. Therefore the healthcare provider may need to be very explicit when describing sexual behaviors to elicit precise information from patients.
Questions for Further Discussion
1. When compared to children raised in other households, do children raised in gay/lesbian homes differ in psychosocial development?
2. Parents who find out they have a daughter or son who is gay/lesbian have what characteristic psychological reaction?
3. In your state, what is the legal status of same-sex households?
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Perrin EC, Cohen KM, Gold M, Ryan C, Savin-Williams RC, Schorzman CM.
Gay and lesbian issues in pediatric health care.
Curr Probl Pediatr Adolesc Health Care. 2004 Nov-Dec;34(10):355-98.
Lesbian mothers, gay fathers, and their children: a review.
J Dev Behav Pediatr. 2005 Jun;26(3):224-4.
Wellings K, Collumbien M, Slaymaker E, Singh S, Hodges Z, Patel D, Bajos N.
Sexual behaviour in context: a global perspective.
Lancet. 2006 Nov 11;368(9548):1706-28.
Homosexuality in children and/or their parents.
Pediatr Nurs. 2007 Sep-Oct;33(5)453-7.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
August 4, 2008