Best Practices to Identify Gay, Lesbian, or Bisexual Youth
Given the increased prevalence of health risk behaviors in GLBQ adolescents demonstrated in the literature, it is important to identify these youth, contrary to the AAP position (Frankowski & AAP Committee on Adolescents, 2004) to provide additional counseling and health care services. These youth would be better served by primary care providers if their sexual orientation was identified in a supportive, confidential environment where services were available to address their health care needs. Key findings and recommendations for sensitive sexual history taking to identify GLBQ youth based upon the review of the literature are outlined in Table 2.
While it is important to recognize that GLBQ youth are an at-risk population, it is essential that providers avoid a narrow view of these adolescents and provide them with the same sensitive, individualized, comprehensive care as they would other adolescents (Catallozzi & Rudy, 2004; Coker, Austin, & Schuster, 2010; Garofolo & Katz, 2001). GLBQ adolescents value the same characteristics in providers and clinical settings as other adolescents (Ginsburg et al., 2009; Hoffman et al., 2002; Rosenthal et al., 1999). Current guidelines for adolescent care should be followed, and counseling should be based on individual risk factors, not solely sexual orientation (Coker et al., 2010).
A number of resources are available online and in print that clinicians may find useful in developing their skills with GLBQ individuals. One such guideline is the Gay and Lesbian Medical Association's Guidelines for Care of Lesbian,Gay, Bisexual, and Transgender Patients (Dunn et al., 2006). Although lacking in evidence-based preventive care guidelines, it contains a wealth of useful information on how to sensitively interact with GLBQ individuals and how to create a welcoming, inclusive practice environment. Additionally, the Gay and Lesbian Medical Association's guideline recommends that providers 1) avoid assumptions about adolescents and their sexual orientation or sexual practices, including assumptions of heterosexuality; 2) use inclusive, gender-neutral language on forms and in adolescent interviews; 3) observe and reflect language and terminology used by adolescents; 4) initiate open discussion of sexual history; and 5) use open-ended questions (see Figure 1). To help create a welcoming, inclusive practice environment, the Gay and Lesbian Medical Association recommends creating, posting, and enforcing a nondiscrimination policy (Dunn et al., 2006). Further, although the display of support symbols, brochures, and education materials pertinent to GLBQ youth are far less important to GLBQ adolescents than provider sensitivity (Ginsburg et al., 2002), the Gay and Lesbian Medical Association recommends the display of such materials (Dunn et al., 2006).
AAP's Bright Futures Guidelines for Health Supervision ofInfants, Children, and Adolescents (Hagan, Shaw, & Duncan, 2008) is widely used and considered to be the standard of care in the provision of pediatric preventive health care in the United States. Providers using Bright Futures, however, should be aware that the guidelines contain limited information on the care of GLBQ adolescents; they echo the findings of Frankowski and AAP Committee on Adolescents (2004) and are not consistent with recommendations based upon this literature review.
Bright Futures health history forms for teens 11 to 14 years of age do not address sexual activity directly, but they include a box to check to indicate if the young adolescent has questions for the provider about sexuality. Forms for middle (15 to 17 years of age) and older (18 to 21 years of age) adolescents ask if the adolescent has ever had sex (a term often interpreted to apply only to sexual intercourse, not all forms of sexual activity), but they also instruct adolescents to skip the rest of the section if their response is "no." These forms ask males if they have "ever had sex with other men," but do not inquire about same-sex activity in females. No questions pertain to relationships of any kind nor same-sex attraction (Hagen et al., 2008).
The Bright Futures forms may be used to encourage discussion, but providers must be aware of their deficiencies in regard to eliciting sexual orientation or attraction in youth. It is particularly important that adolescents who indicate they are not sexually active still be interviewed regarding sexuality regardless of the forms' instruction to skip to the next section. Providers should review all adolescent history forms or electronic medical records used in their practice to determine their appropriateness for obtaining confidential, unbiased, sexual orientation and practice histories.
Discussion and Recommendations
Given the increased prevalence of health risk behaviors in GLBQ adolescents demonstrated in the literature, it is important to identify these youth, contrary to the AAP position (Frankowski & AAP Committee on Adolescents, 2004) to provide additional counseling and health care services. These youth would be better served by primary care providers if their sexual orientation was identified in a supportive, confidential environment where services were available to address their health care needs. Key findings and recommendations for sensitive sexual history taking to identify GLBQ youth based upon the review of the literature are outlined in Table 2.
Recommendations for Sensitive Care of GLBQ Adolescents
While it is important to recognize that GLBQ youth are an at-risk population, it is essential that providers avoid a narrow view of these adolescents and provide them with the same sensitive, individualized, comprehensive care as they would other adolescents (Catallozzi & Rudy, 2004; Coker, Austin, & Schuster, 2010; Garofolo & Katz, 2001). GLBQ adolescents value the same characteristics in providers and clinical settings as other adolescents (Ginsburg et al., 2009; Hoffman et al., 2002; Rosenthal et al., 1999). Current guidelines for adolescent care should be followed, and counseling should be based on individual risk factors, not solely sexual orientation (Coker et al., 2010).
A number of resources are available online and in print that clinicians may find useful in developing their skills with GLBQ individuals. One such guideline is the Gay and Lesbian Medical Association's Guidelines for Care of Lesbian,Gay, Bisexual, and Transgender Patients (Dunn et al., 2006). Although lacking in evidence-based preventive care guidelines, it contains a wealth of useful information on how to sensitively interact with GLBQ individuals and how to create a welcoming, inclusive practice environment. Additionally, the Gay and Lesbian Medical Association's guideline recommends that providers 1) avoid assumptions about adolescents and their sexual orientation or sexual practices, including assumptions of heterosexuality; 2) use inclusive, gender-neutral language on forms and in adolescent interviews; 3) observe and reflect language and terminology used by adolescents; 4) initiate open discussion of sexual history; and 5) use open-ended questions (see Figure 1). To help create a welcoming, inclusive practice environment, the Gay and Lesbian Medical Association recommends creating, posting, and enforcing a nondiscrimination policy (Dunn et al., 2006). Further, although the display of support symbols, brochures, and education materials pertinent to GLBQ youth are far less important to GLBQ adolescents than provider sensitivity (Ginsburg et al., 2002), the Gay and Lesbian Medical Association recommends the display of such materials (Dunn et al., 2006).
Bright Futures
AAP's Bright Futures Guidelines for Health Supervision ofInfants, Children, and Adolescents (Hagan, Shaw, & Duncan, 2008) is widely used and considered to be the standard of care in the provision of pediatric preventive health care in the United States. Providers using Bright Futures, however, should be aware that the guidelines contain limited information on the care of GLBQ adolescents; they echo the findings of Frankowski and AAP Committee on Adolescents (2004) and are not consistent with recommendations based upon this literature review.
Bright Futures health history forms for teens 11 to 14 years of age do not address sexual activity directly, but they include a box to check to indicate if the young adolescent has questions for the provider about sexuality. Forms for middle (15 to 17 years of age) and older (18 to 21 years of age) adolescents ask if the adolescent has ever had sex (a term often interpreted to apply only to sexual intercourse, not all forms of sexual activity), but they also instruct adolescents to skip the rest of the section if their response is "no." These forms ask males if they have "ever had sex with other men," but do not inquire about same-sex activity in females. No questions pertain to relationships of any kind nor same-sex attraction (Hagen et al., 2008).
The Bright Futures forms may be used to encourage discussion, but providers must be aware of their deficiencies in regard to eliciting sexual orientation or attraction in youth. It is particularly important that adolescents who indicate they are not sexually active still be interviewed regarding sexuality regardless of the forms' instruction to skip to the next section. Providers should review all adolescent history forms or electronic medical records used in their practice to determine their appropriateness for obtaining confidential, unbiased, sexual orientation and practice histories.
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