Psychosocial issues in primary care of lesbian, gay, bisexual, and transgender youth

Lesbian, gay, bisexual, and transgender youth are at risk for a multitude of physical, emotional, and social health problems. During the past decade it has been well documented that these youth have higher-than-average rates of depression, suicide attempts, substance abuse, sexually transmitted diseases, school failure, family rejection, and homelessness. The focus of this article is to outline skills and strategies that can assist the health practitioner in creating an optimal health care experience for sexual minority youth. Models of individual and family adaptation, a clinical path, and a referral list are presented. Current health care delivery sites are examined, and recommendations are given for improvement of both practitioner skills and health care programs targeting these youth.     

Health care issues of gay and lesbian youth.

Gay and lesbian youth are adolescents who, in many ways, are no different from their peers. What distinguishes homosexual youth from other adolescent populations is the emotional, psychological and physical trauma resulting from the homophobia they experience in their daily lives. Although suicide, HIV infection, substance use, and violence appear to disproportionately affect this population, most homosexual youth grow up healthy and happy. Frequently lost in discussions of risk and risk behaviors is an appreciation of the strengths very much present in these young people. Health care providers must remain aware of the unique issues and health risks of homosexual youth but must also remember to address each patient as an individual within the context of general adolescent development. By doing so, pediatricians can play a vital role in preserving and enhancing the health of this "at-risk" population.     

Nondisclosure of sexual orientation to a physician among a sample of gay, lesbian, and bisexual youth

BACKGROUND: The American Medical Association, the American Academy of Pediatrics, and the Society for Adolescent Medicine recommend discussing sexual orientation as part of the health supervision of all adolescents. Little is known about whether lesbian, gay, and bisexual (LGB) youth hide their orientation from health care providers, which can potentially lead to missed opportunities in identifying individual health risks and provide appropriate screening and counseling. OBJECTIVES: To describe the health care experiences of a nonclinical sample of LGB youth and identify factors associated with disclosure and nondisclosure of orientation to physicians. DESIGN: Community-based participatory study using a self-administered questionnaire. SETTING: Los Angeles youth empowerment conference held in October 2003 targeting high school-aged LGB youth. PARTICIPANTS: One hundred thirty-one youth aged 14 to 18 years who identified themselves as LGB. Main Outcome Measure Physician's knowledge of participant's sexual orientation. RESULTS: Thirty-five percent of the sample reported that their physician knew they were LGB. Bisexual youth were less likely than gay and lesbian youth to have disclosed. The strongest predictor of disclosure was having discussed sex or sexual health of any kind with a physician (odds ratio, 15.47; 95% confidence interval, 4.34-55.18). When asked what a physician could do to make talking about being LGB more comfortable, 64% of participants chose the survey response, "Just ask me." CONCLUSIONS: Even among a nonclinical sample of LGB youth who were open enough about their orientation to attend a conference on the subject, only 35% reported that their physician knew their orientation. The results indicate that physicians had not discussed sexuality with most LGB youth in the study and that most youth would welcome such a discussion.     

Risk factors for attempted suicide in gay and bisexual youth

Studies of human sexuality have noted high rates of suicidality among homosexual youth, but the problem has not been systematically examined. This work was undertaken to identify risk factors for suicide attempts among bisexual and homosexual male youth. Subjects were 137 gay and bisexual males, 14 through 21 years of age, from the upper Midwest and Pacific Northwest. Forty-one subjects (41/137) reported a suicide attempt; and almost half of them described multiple attempts. Twenty-one percent of all attempts resulted in medical or psychiatric admissions. Compared with non-attempters, attempters had more feminine gender roles and adopted a bisexual or homosexual identity at younger ages. Attempters were more likely than peers to report sexual abuse, drug abuse, and arrests for misconduct. The findings parallel previous studies' results and also introduce novel suicide risk factors related to gender nonconformity and sexual milestones.     

Bacterial sexually transmitted infections in gay, lesbian, and bisexual adolescents: medical and public health perspectives

Gay, lesbian, and bisexual adolescents, like all adolescents who engage in high-risk sexual behaviors, are at elevated risk for acquiring sexually transmitted infections (STIs). Personal sexual risk factors and issues related to access to care complicate the lives of youth who engage in same-gender sexual activity and who may or may not self-identify as gay, lesbian, or bisexual. Whereas epidemiologic rates of gonorrhea, chlamydia, and syphilis generally have trended downward in adolescents as a whole during the past 15 years, rates for these common reportable bacterial STIs have increased overall during recent years among men who have sex with men. This article focuses on bacterial STIs in youth with same-gender sexual activity. An understanding of trends among gay, lesbian, and bisexual youth remains incomplete, given the absence of consistent and uniform mechanisms for collecting data on sexual behaviors in adolescents and difficulties in associating these behaviors with reportable STIs. Special attention should be given to the screening, diagnosis, and treatment of bacterial STIs in those who engage in same-sex behavior, as new recommendations from the Centers for Disease Control and Prevention have been made available. It is critical that healthcare providers who work with adolescents be aware of the assortment of specific healthcare needs of gay, lesbian, and bisexual youth and address them appropriately in the clinical setting. Medical providers may be one of few true advocates for this often-marginalized adolescent population and have the power to have a positive influence on health promotion and education efforts.     

Health care for children and youth in the United States: 2001 annual report on access, utilization, quality, and expenditures.

OBJECTIVES: To provide an update on insurance coverage, use of health care services, and health expenditures for children and youth in the United States and new information on parents' perceived quality of care for their children and to provide information on variation in hospitalizations for children from a 24-state hospital discharge data source. METHODS: The data on insurance coverage, utilization, expenditures, and perceived quality of care come from the Medical Expenditure Panel Survey. The data on hospitalizations come from the Nationwide Inpatient Sample, which is part of the Healthcare Cost and Utilization Project. Both data sets are maintained by the Agency for Healthcare Research and Quality. RESULTS: In 2000, 64.5% of children were privately insured, 21.6% were insured through public sources, and 13.9% were uninsured. Children aged 15-17 years were more likely to be uninsured than children 1-4 years old. Children without health insurance coverage were less likely to use health care services, and when they did, their rates of utilization and expenditures were lower than insured children. Publicly insured children were the most likely to use hospital inpatient and emergency department (ED) care. Being black or Hispanic and living in families with incomes below 200% of the poverty line were associated with lower utilization and expenditures. A small proportion of children account for the bulk of health care expenditures: approximately 80% of all children's health care expenditures are attributable to 20% of children who used medical services. Although most parents report that their experiences with health care for their children are good, there are significant variations by type of insurance coverage. There are substantial differences in average length of hospitalization across the United States, ranging from 2.9-4.1 days, and rates of hospital admission through the ED, which vary across states from 10%-25%. Injuries are a major reason for hospitalization, accounting for 1 in 6 hospital stays among 10- to 14-year-olds. In the 10- to 17-year age group, more than 1 in 7 hospital stays are due to mental disorders. Among 15- to 17-year-olds, more than one third of all hospital stays are related to childbirth and pregnancy. The top 10 most common conditions treated in the hospital account for 40%-60% of all hospital stays. CONCLUSION: Children's use of health care services varies considerably by the type of health insurance coverage, race/ethnicity, and family income. Quality of care, as measured by parents' experiences of care, also varies by type of coverage. There is substantial variation in use of hospital services across states.