Patient Presentation
A group of residents and an attending physician were discussing adolescent sexual health. During the conversation, the question came up whether lesbian girls were at risk for pregnancy. The residents were split on the issue and the attending said she wasn’t sure how much the risk was increased, but that adolescents girls were at risk, and adolescents often were learning about their sexuality at this time, so it seemed that lesbian girls might be at the same risk or potentially even higher risk. During the clinic afternoon, the attending was able to find and circulated the newest technical report from the American Academy of Pediatrics which stated that “…sexual minority youth do not necessarily engage in sexual behaviors that are predicted by their orientation.” It also said that sexual minority youth were more likely to have had intercourse, to have started sexual intercourse before age 13 years, to have had multiple partners, and fewer were likely to use condoms and other forms of birth control/STI prevention. Girls who were having sex with other girls/women were more likely to become pregnant than girls who were only have sex with boys/men.
Discussion
LGBTQ (lesbian, gay, bisexual, transgender and questioning people) terminology describes sexual orientation, not sexual behavior and is a common term used. Individuals may reject this term and prefer other terminology such as a man having sex with other men (MSM) or a woman having sex with other women (WSW). Over time terminology may change also, such as the word queer that has had a negative connotation, but in contemporary usage is also used as a unifying term for anyone who is a sexual minority.
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 an individual who is not sure about their sexual orientation.
For additional information about LGBTQ youth, see How Can I Make My Sexual Interview More Gender Neutral?
Learning Point
LGBTQ youth in general have good physical and mental health and like all youth should be provided comprehensive primary and specialty care.
LGBTQ youth do have certain risk factors based on current research and therefore should be screened and treated as appropriate. There is signficantly less research for transgender youth compared to other sexual minority groups.
- Mental health – screening for mood disorders, depression and suicide risk and body image/eating disorders is usually part of comprehensive care, but special attention may be needed for LGBTQ youth. Lesbian girls may be more contented with their bodies than heterosexual girls, but gay boys may be less contented than their heterosexual counterparts.
- Physical health – obesity is screened for in all youth but LGBTQ are at higher risk
- Sexual Health
- Pregnancy – increased risk for lesbian girls relative to heterosexual girls – screening and testing as appropriate
- Sexually transmitted infections – increased risk for both gay and lesbian youth, HIV/AIDs is specifically higher in gay youth.
It is recommended to screen yearly if in a monogamous relationship that has 100% condom use and no substance abuse, otherwise more frequent screening is recommended.- Females – follow CDC guidelines and also consider specific screening for HIV, HSV, HPV, Chlamydia, Syphilis, and bacterial vaginosis
- Males – follow CDC guidelines and strongly consider specific screening for Hepatitis B, HIV, HSV, HPV, Chlamydia, Neisseria, and Syphilis. Hepatitis C should be screened for if current or past drug user or HIV positive.
- Prevention
- Condoms, dental dams should be promoted for any contacts
- HPV vaccine should also be promoted for all youth
- Birth control and emergency contraceptive should be discussed and provided to youth
Questions for Further Discussion
1. What role does family acceptance of LGBTQ youth provide?
2. What are some ways a primary care office can show adolescents that it is open to discussing sexual issues?
3. What are your local laws for providing treatment and counseling for sexual health issues such as pregnancy, birth control, STIs for adolescents?
Related Cases
- Symptom/Presentation
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Ryan C, Russell ST, Huebner D, Diaz R, Sanchez J. Family acceptance in adolescence and the health of LGBT young adults. J Child Adolesc Psychiatr Nurs. 2010 Nov;23(4):205-13.
The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding.
Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities.
Washington (DC): National Academies Press (US); 2011.
Kincaid C, Jones DJ, Sterrett E, McKee L. A review of parenting and adolescent sexual behavior: the moderating role of gender. Clin Psychol Rev. 2012 Apr;32(3):177-88.
Levin DA and the Committee on Adolescence. Office-Based Care for Lesbian, Gay, Bisexual, Transgender, and Questioning Youth. Pediatrics. 2013;132:e297 -e313
ACGME Competencies Highlighted by Case
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.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
16. Learning of students and other health care professionals is facilitated.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 