HOMOSEXUALITY AND ADOLESCENCE

Committee on Adolescence

The American Academy of Pediatrics issued its first statement on homosexuality and adolescence in 1983. The past decade has witnessed increased awareness of homosexuality, changing attitudes toward this sexual orientation, and the growing impact of the human immunodeficiency virus (HIV). Therefore, an updated statement on homosexuality and adolescence is timely.

Homosexuality is the persistent sexual and emotional attraction to members of one's own gender and is part of the continuum of sexual expression. Many gay and lesbian youths first become aware of and experience their sexuality during adolescence. Therefore, pediatricians who care for teenagers need to understand the unique medical and psychosocial issues facing homosexually oriented youths (see Table 1 for a definition of terms).

ETIOLOGY AND PREVALENCE

Homosexuality has existed in most societies for as long as recorded descriptions of sexual beliefs and practices have been available. Societal attitudes toward homosexuality have had a decisive impact on the extent to which individuals have hidden or made known their sexual orientation.

In 1973, the American Psychiatric Association reclassified homosexuality as a sexual orientation/expression rather than as a mental disorder. [1] The etiology of homosexuality remains unclear, but the current literature and the vast majority of scholars in this field state that one's sexual orientation is not a choice, that is, individuals no more choose to be homosexual than heterosexual. [2,3] However, the expression of sexual behaviors and lifestyle is a choice for all teenagers regardless of sexual orientation.

During the adolescent years, many youths engage in sexual experimentation. Sexual behavior during this period does not predict future sexual orientation. Gay, lesbian, and heterosexual youths may engage in sexual activities with members of the same or opposite sex. Kinsey et al, [4,5] from their studies in the 1930s and 1940s, reported that 37% of men had at least one homosexual experience resulting in orgasm. From the same cohort, Kinsey reported that 4% of women and 10% of men were exclusively homosexual for at least 3 years of their lives. Sorenson [6] surveyed a group of 16- to 19-year-olds and reported that 6% of females and 17% of males had at least one homosexual experience. While the Kinsey data suggest that 4% of adult men and 2% of adult women are exclusively homosexual in their behavior and fantasies, the current prevalence of homosexual behavior and identity among adolescents remains to be defined.

SPECIAL CONCERNS

Gay and lesbian adolescents share many of the developmental tasks of their heterosexual peers. These include establishing a sexual identity and deciding on sexual behaviors, whether choosing to engage in sexual intercourse or to abstain. Due to the seriousness of sexually transmitted diseases (STDs), abstinence should be promoted as the safest choice for all adolescents. However, not all youths will choose abstinence. The current reality is that a large number of adolescents are sexually active. Therefore, all adolescents should receive sexuality education and have access to health care resources. It is important to provide appropriate anticipatory guidance to all youths regardless of their sexual orientation. Physicians must also be aware of the important medical and psychosocial needs of gay and lesbian youths. [7]

HIV

The epidemic of the HIV infection highlights the urgency of making preventive services and medical care available to all adolescents regardless of sexual orientation or activity. Heterosexual and homosexual transmission of HIV infection is well established. The role of injectable drugs of abuse in HIV transmission is also well known. [3,8] Sex between males accounts for about half of the non-transfusion-associated cases of acquired immunodeficiency syndrome (AIDS) among males between the ages of 13 and 19 years. [8] While not all gay adolescents engage in high-risk sex (or even have sex), their vulnerability to HIV infection is well recognized. The pediatrician should encourage adolescents to practice abstinence. However, many will not heed this important message. Thus, practical, specific advice about condom use and other forms of safer sex should be included in all sexuality education and prevention discussions.

Issue of Trust

Quality care can be facilitated if the pediatrician recognizes the specific challenges and rewards of providing services for gay and lesbian adolescents. This care begins with the establishment of trust, respect, and confidentiality between the pediatrician and the adolescent. Many gay and lesbian youths avoid health care or discussion of their sexual orientation out of fear that their sexual orientation will be disclosed to others. The goal of the provider is not to identify all gay and lesbian youths, but to create comfortable environments in which they may seek help and support for appropriate medical care while reserving the right to disclose their sexual identity when ready. Pediatricians who are not comfortable in this regard should be responsible for seeing that such help is made available to the adolescent from another source.

History

A sexual history that does not presume exclusive heterosexuality should be obtained from all adolescents. [3,9] Confidentiality must be emphasized except in cases in which sexual abuse has occurred. It is vital to identify high-risk behavior (anal or vaginal coitus, oral sex, casual and/or multiple sex partners, substance abuse, and others).

Physical Examination

A thorough and sensitive history provides the groundwork for an accurate physical examination for youths who are sexually experienced. [10] Depending on the patient's sexual practices, a careful examination includes assessment of pubertal staging, skin lesions (including cutaneous manifestations of STDs, bruising, and other signs of trauma), lymphadenopathy (including inguinal), and anal pathology (including discharge, venereal warts, herpetic lesions, fissures, and others). Males need evaluation of the penis (ulcers, discharge, skin lesions), scrotum, and prostate (size, tenderness). Females need assessment of their breasts, external genitalia, vagina, cervix, uterus, and adnexa.

Laboratory Studies

All males engaging in sexual intercourse with other males should be routinely screened for STDs, including gonorrhea, syphilis, chlamydia, and enteric pathogens. The oropharynx, rectum, and urethra should be examined and appropriate cultures obtained when indicated. [3,9]

Immunity to hepatitis B virus should be assessed. Immunization is recommended for all sexually active adolescents and should be provided for all males who are having or anticipate having sex with other males. [11] HIV testing with appropriate consent should be offered; this includes counseling before and after voluntary testing.

Women who have sex exclusively with other women have a low incidence of STDs, but can transmit STDs and potentially HIV if one partner is infected. Since lesbian women who engage in unprotected sex with men face risks of both sexually acquired infections and pregnancy, the pediatrician should offer them realistic birth control information and counseling on STD prevention.

PSYCHOSOCIAL ISSUES

The psychosocial problems of gay and lesbian adolescents are primarily the result of societal stigma, hostility, hatred, and isolation. [12] The gravity of these stresses is underscored by current data that document that gay youths account for up to 30% of all completed adolescent suicides. [13] Approximately 30% of a surveyed group of gay and bisexual males have attempted suicide at least once. [14] Adolescents struggling with issues of sexual preference should be reassured that they will gradually form their own identity [15] and that there is no need for premature labeling of one's sexual orientation. [16] A theoretical model of stages for homosexual identity development composed by Troiden [17] is summarized in Table 2. The health care professional should explore each adolescent's perception of homosexuality, and any youth struggling with sexual orientation issues should be offered appropriate referrals to providers and programs that can affirm the adolescent's intrinsic worth regardless of sexual identity. Providers who are unable to be objective because of religious or other personal convictions should refer patients to those who can.

Gay or lesbian youths often encounter considerable difficulties with their families, schools, and communities. [16,18,19] These youths are severely hindered by societal stigmatization and prejudice, limited knowledge of human sexuality, a need for secrecy, a lack of opportunities for open socialization, and limited communication with healthy role models. Subjected to overt rejection and harassment at the hands of family members, peers, school officials, and others in the community, they may seek, but not find, understanding and acceptance by parents and others. Parents may react with anger, shock, and/or guilt when learning that their child is gay or lesbian.

Peers may engage in cruel name-calling, ostracize, or even physically abuse the identified individual. School and other community figures may resort to ridicule or open taunting, or they may fail to provide support. Such rejection may lead to isolation, runaway behavior, homelessness, domestic violence, depression, suicide, substance abuse, and school or job failure. Heterosexual and/or homosexual promiscuity may occur, including involvement in prostitution (often in runaway youths) as a means to survive. Pediatricians should be aware of these risks and provide or refer such youths for appropriate counseling.

Disclosure

The gay or lesbian adolescent should be allowed to decide when and to whom to disclose his/her sexual identity. In particular, the issue of informing parents should be carefully explored so that the adolescent is not exposed to violence, harassment, or abandonment. Parents and other family members may derive considerable benefit and gain understanding from organizations such as Parents and Friends of Lesbians and Gays (PFLAG). [3,18]

Concept of Therapy

Confusion about sexual orientation is not unusual during adolescence. Counseling may be helpful for young people who are uncertain about their sexual orientation or for those who are uncertain about how to express their sexuality and might profit from an attempt at clarification through a counseling or psychotherapeutic initiative. Therapy directed specifically at changing sexual orientation is contraindicated, since it can provoke guilt and anxiety while having little or no potential for achieving changes in orientation. While there is no current literature clarifying whether sexual abuse can induce confusion in one's sexual orientation, those with a history of sexual abuse should always receive counseling with appropriate mental health specialists. Therapy may also be helpful in addressing personal, family, and environmental difficulties that are often concomitants of the emerging expression of homosexuality. Family therapy may also be useful and should always be made available to the entire family when major family difficulties are identified by the pediatrician as parents and siblings cope with the potential added strain of disclosure.

SUMMARY OF PHYSICIAN GUIDELINES

Pediatricians should be aware that some of the youths in their care may be homosexual or have concerns about sexual orientation. Caregivers should provide factual, current, nonjudgmental information in a confidential manner. These youths may present to physicians seeking information about homosexuality, STDs, substance abuse, or various psychosocial difficulties. The pediatrician should ensure that each youth receives a thorough medical history and physical examination (including appropriate laboratory tests), as well as STD (including HIV) counseling and, if necessary, appropriate treatment. The health care professional should also be attentive to various potential psychosocial difficulties and offer counseling or refer for counseling when necessary.

The American Academy of Pediatrics reaffirms the physician's responsibility to provide comprehensive health care and guidance for all adolescents, including gay and lesbian adolescents and those young people struggling with issues of sexual orientation. The deadly consequences of AIDS and adolescent suicide underscore the critical need to address and seek to prevent the major physical and mental health problems that confront gay and lesbian youths in their transition to a healthy adulthood.

TABLE 1. Definitions of Terms

Coming out:

The acknowledgment of one's homosexuality and the process of sharing that information with others.

Gender identity:

The personal sense of one's integral maleness or femaleness; typically occurs by 3 years of age.

Gender role:

The public expression of gender identity; the choices and actions that signal to others a person's maleness or femaleness; one's sex role.

Heterosexist bias:

The conceptualization of human experience in strictly heterosexual terms and consequently ignoring, invalidating, or derogating homosexual behaviors and sexual orientation.

[19]

Homophobia:

The irrational fear or hatred of homosexuality, which may be expressed in stereotyping, stigmatization, or social prejudice [18]; it may also be internalized in the form of self-hatred

.

In the closet:

Nondisclosure or hiding one's sexual orientation from others

.

Sexual orientation:

The persistent pattern of physical and/or emotional attraction to members of the same or opposite sex Included in this are homosexuality (same-gender attractions); bisexuality (attractions to members of both genders); and heterosexuality (opposite-gender attractions). The terms preferred by most homosexuals today are lesbian women or gay men

.

Transsexual:

An individual who believes himself or herself to be of a gender different from his or her assigned biologic gender (gender identity does not match anatomic gender)

.

Transvestite:

An individual who dresses in the clothing of the opposite gender and derives pleasure from this action. This is not indicative of one's sexual orientation

.

TABLE 2. Stages of Homosexual Identity Formation [*]

Sensitization:

The feeling of differentness as a prepubertal child or adolescent. The first recognition of attraction to members of the same gender before or during puberty

.

Sexual identity confusion:

Confusion and turmoil stemming from self-awareness of same-gender attractions. Often this first occurs during adolescence. This confusion usually is not so much due to a questioning of one's feelings as it is to the attempt to reconcile the feelings with negative societal stereotypes. The lack of accurate knowledge about homosexuality, the scarcity of positive gay and lesbian role models, and the absence of an opportunity for open discussion and socialization as a gay or lesbian person contribute to this confusion. During this stage the adolescent develops a coping strategy to deal with social stigma

.

Sexual identity assumption:

The process of acknowledgment and social and sexual exploration of one's own gay or lesbian identity and consideration of homosexuality as a lifestyle option. This stage typically persists for several years during and after late adolescence

.

Integration and commitment:

The stage at which a gay or lesbian person incorporates his/her homosexual identity into a positive self-acceptance. This gay or lesbian identity is then increasingly and confidently shared with selected others. Many gays and lesbians may never reach this stage; those who do are typically in adulthood when this acceptance occurs

.

* From Troiden. [17]

COMMITTEE ON ADOLESCENCE, 1992 TO 1993
Roberta K. Beach, MD, Chair
Suzanne Boulter, MD
Marianne E. Felice, MD
Edward M. Gotlieb, MD
Donald E. Greydanus, MD
James C. Hoyle Jr, MD
I. Ronald Shenker, MD

LIAISON REPRESENTATIVES
Richard E. Smith, MD
American College of Obstetricians and Gynecologists

Michael Maloney, MD
American Academy of Child and Adolescent Psychiatry

Diane Sacks, MD
Canadian Paediatric Society

SECTION LIAISON
Samuel Leavitt, MD
Section on School Health

CONSULTANTS
Donna Futterman, MD
Albert Einstein College of Medicine

John D. Rowlett, MD
Children's Hospital of Savannah, GA

S. Kenneth Schonberg, MD
Albert Einstein College of Medicine

REFERENCES

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed, revised. Washington, DC: American Psychiatric Association; 1987

2. Savin-Williams RC. Theoretical perspectives accounting for adolescent homosexuality. J Adolesc Health Care. 1988;9:2

3. Rowlett J, Patel DR, Greydanus DE. Homosexuality. In: Greydanus DE, Wolraich M, eds. Behavioral Pediatrics. New York, NY: Springer-Verlag; 1992:37-54

4. Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior in the Human Male. Philadelphia, PA: WB Saunders; 1948

5. Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior in the Human Female. Philadelphia, PA: WB Saunders; 1953

6. Sorenson RC. Adolescent Sexuality in Contemporary America. New York, NY: World Publishing; 1973

7. Remafedi GJ. Adolescent homosexuality: psychosocial and medical implications. Pediatrics. 1987;79:331-337

8. Centers for Disease Control. AIDS Surveillance Update. Atlanta, GA; March 1991

9. Remafedi GJ. Sexually transmitted diseases in homosexual youth. Adolesc Med State Art Rev. 1990;1:565-581

10. Brookman RR. Reproductive health assessment of the adolescent. In: Hofmann AD, Greydanus DE, eds. Adolescent Medicine. 2nd ed. Norwalk, CT: Appleton-Lange; 1989:347-351

11. Centers for Disease Control. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee. MMWR. 1991;40(No. RR-13):13-16

12. Martin AD. Learning to hide: the socialization of the gay adolescent. In: Feinstein SC, Looney JG, Schwarzenberg AZ, Sorosky AD, eds. Adolescent Psychiatry. Chicago, IL: University of Chicago Press; 1982:52-65

13. US Dept of Health and Human Services. Report of the Secretary's Task Force on Youth Suicide. Washington, DC: US Dept of Health and Human Services; 1989

14. Remafedi G, Farrow JA, Deisher RW. Risk factors for attempted suicide in gay and bisexual youth. Pediatrics. 1991;87:869-875

15. Remafedi G, Resnick M, Blum R, et al. Demography of sexual orientation in adolescents. Pediatrics. 1992;89:714-721

16. Greydanus DE, Dewdney D. Homosexuality in adolescence. Semin Adolesc Med. 1985;1:117-129

17. Troiden RR. Homosexual identity development. J Adolesc Health Care. 1988;9:105-113

18. Peterson PK, ed. Special symposium: gay and lesbian youth. In: American Academy of Pediatrics, Adolescent Health Section Newsletter. 1991;12(1):3-41

19. Herek GM, Kimmel DC, Amaro H, et al. Avoiding heterosexist bias in psychological research. Am Psychol. 1991;46:957-963