By Angela Kade Goepferd, MD, FAAP, Director of Medical Education, Children’s Hospitals and Clinics of Minnesota and Rhamy N. Magid, MD
As pediatricians, we are dedicated to the health of all children. Increasingly, this means addressing matters of sexual health, including sexual orientation and gender identity. Issues surrounding the rights of the lesbian, gay, bisexual, transgender and questioning (LGBTQ) community have finally come to the forefront of public discourse in our country, presenting us with the opportunity to highlight the health needs of our LGBTQ patients.
As noted by the AAP Committee on Adolescence, “Being a member of this group of teenagers is not, in itself, a risk behavior…however, the presence of stigma from homophobia and heterosexism often leads to psychological distress, which may be accompanied by an increase in risk behaviors.” LGBTQ youth are at significantly higher risk than their peers for a number of health problems, including depression, suicidality, substance abuse, anxiety, eating disorders, homelessness, bullying, physical assault, survival sex, and sexual abuse. They are also significantly less likely to feel supported and understood by their parents, teachers and health care providers.
How can we make a positive difference in these children’s lives? Below, we will offer some starting suggestions for working toward inclusive and equitable care for our LGBTQ patients. As we begin to address some unique considerations for these patients, it is crucial to remember that they are fundamentally just like all other children and adolescents. It’s important to address all the same developmental, historical and physical aspects of the visit that you would with any other pediatric or adolescent patient. These are kids, just like any other, and neither their identities nor their health are defined entirely by their sexual orientation and/or gender identity. The following are first steps to create inclusive and safe spaces, and to promote optimal health for LGBTQ youth.
Create a Welcoming Environment
Unfortunately, some LGBTQ patients delay or avoid medical care due to fear of discrimination and stigma. It is our duty as care providers to create a welcoming environment for LGBTQ youth and to make it clear that our offices are safe spaces where their identity will be respected and nurtured. A 2009 assessment from the University of Minnesota School of Public Health suggests that patients can be put at ease by even the simplest of “structural elements,” such as a rainbow sticker on a window or visible LGBTQ health pamphlets and brochures.
How your patients are treated by every person they see from the moment they enter your doors will impact their experience. The front desk staff can so easily – and unintentionally – set a negative tone by using a non-preferred name or pronoun, asking an unnecessary question that forces a patient to out him or herself; or giving a facial expression that suggests anything other than a warm and professional greeting.
Some questions to consider:
1. While waiting in the lobby, are your patients surrounded by images or literature that are neutral with respect to expectations of gender and sexual orientation?
2. What type of cultural inclusion and sensitivity training have you and your staff received? Has culturally responsive education about LGBTQ health been offered?
3. What type of all-gender spaces do you have available? If your office has gendered facilities, such as restrooms, have all-gender or gender neutral options been made available?
4. What assessment and intake questions do you ask your patients? Are there multiple options available for sexual identity? For gender identity? How are you documenting and communicating a patient’s preferred name and pronoun? Are your questions about parents and guardians inclusive of all families?
5. Does your Electronic Health Record (EHR) allow accurate (and if necessary, confidential) documentation of the above questions?
Strategies in the Exam Room
With every adolescent patient, it is critical to devote a component of the visit to obtaining a confidential psychosocial history. Before you ask about sexual orientation, be sure you know why you are asking and what you are going to do with the information. Any questions about a patient’s sexual orientation should prompt follow up questions about sexual behavior, as well as environmental risk factors. A simple yet effective query is, “Are you dating or seeing anyone?”, which can be followed with the question, “Are you attracted to boys, girls or both?” These questions leave the door open for them to answer honestly without judgment or expectation.
Remember that a person’s sexual identity (straight, gay, lesbian, bisexual, etc) does not necessarily define behavior. It is important to follow any questions about identity with specific questions about behavior or sexual activity. Knowing about the sex of the partner(s) and the type of sexual activity (e.g. vaginal, anal, oral) helps us know what STI testing, if any, to perform, as well as what specific types of STI prevention and contraception to discuss.
After assessing identity and activity, it is important to ask questions pertaining to the child’s support system, safety and mood. We know that LGBTQ children who experience rejection by their parents are at significantly increased risk of adverse outcomes, including suicide. Ask your patient questions such as: “Does anyone in your family know that you are LGBTQ? How have they responded?”; “Who can you talk to about your sexuality/ gender identity?” Ask about other supportive friends or family. Ask whether your patient feels safe at home and in school. Assess for suicidality. Finally, make sure you have a list of referral options in case you obtain positive responses to your screening questions.
Taking the Next Steps
LGBTQ children and adolescents experience all the same physical, social and emotional challenges as their heterosexual and cis-gendered peers. They also have the same capacity for resilience and success, as long as they are nurtured. Once you have identified orientation/identity and engaged in appropriate screening and counseling, the next step is to ensure the safety and well-being of your patient outside of your exam room.
Part of creating an inclusive and equitable care experience for your LGBTQ patients is advocating for them in your interactions with their parent(s), their school and in other health policy arenas. It is critical to counsel parents about the detrimental impact that parental rejection can have on their child’s health. Conversely, a parent’s expression of unconditional love for their LGBTQ child can make the difference between life and death. We should be available to communicate with school administrators as needed, particularly in cases of bullying or gender transition. Finally, as clinicians, we have a powerful voice in the public arena and at the legislature, advocating for safe spaces and inclusive policies for our LGBTQ patients
As pediatric and adolescent care providers, we have a significant role to play in addressing health disparities facing LGBTQ youth and creating comprehensive, culturally responsive, quality healthcare for these children and adolescents. We can do this by creating welcoming environments in our clinics and other care settings, by educating ourselves and our staff to be responsive to the unique needs of our LGBTQ patients and by advocating for improved policies and protections for these at-risk children and adolescents. Together we can create an equitable and inclusive care experience for all of our patients and their families.