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Pediatric Collections: LGBTQ+: Support and Care (Part 2: Health Concerns and Disparities)

By American Academy of Pediatrics

Although most lesbian, gay, bisexual, transgender, and questioning youths are quite resilient and emerge from adolescence as healthy adults, the effects of stigma and heterosexism can contribute to health disparities. Part 2 of this first-of-its-kind 3-part series can help pediatric primary care providers become stronger allies for TGD patients and their families in the clinic, community, and beyond, providing the promise of both a medical home and a future that celebrates people for being true to themselves.


    1. Page 5
      Address correspondence to Caitlin Ryan, PhD, ACSW, Adolescent Health Initiatives, César E. Chávez Institute, College of Ethnic Studies, San Francisco State University, 3004 16th St, 301, San Francisco, CA 94103. E-mail: caitlin@sfsu.edu

      OBJECTIVE We examined specific family rejecting reactions to sexual orientation and gender expression during adolescence as predictors of current health problems in a sample of lesbian, gay, and bisexual young adults.

      METHODS On the basis of previously collected in-depth interviews, we developed quantitative scales to assess retrospectively in young adults the frequency of parental and caregiver reactions to a lesbian, gay, or bisexual sexual orientation during adolescence. Our survey instrument also included measures of 9 negative health indicators, including mental health, substance abuse, and sexual risk. The survey was administered to a sample of 224 white and Latino self-identified lesbian, gay, and bisexual young adults, aged 21 to 25, recruited through diverse venues and organizations. Participants completed self-report questionnaires by using either computer-assisted or pencil-and-paper surveys.

      RESULTS Higher rates of family rejection were significantly associated with poorer health outcomes. On the basis of odds ratios, lesbian, gay, and bisexual young adults who reported higher levels of family rejection during adolescence were 8.4 times more likely to report having attempted suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to report having engaged in unprotected sexual intercourse compared with peers from families that reported no or low levels of family rejection. Latino men reported the highest number of negative family reactions to their sexual orientation in adolescence.

      CONCLUSIONS This study establishes a clear link between specific parental and caregiver rejecting behaviors and negative health problems in young lesbian, gay, and bisexual adults. Providers who serve this population should assess and help educate families about the impact of rejecting behaviors. Counseling families, providing anticipatory guidance, and referring families for counseling and support can help make a critical difference in helping decrease risk and increasing well-being for lesbian, gay, and bisexual youth.

    2. Page 12

      OBJECTIVES Sexual orientation disparities in adolescent depressive symptoms are well established, but reasons for these disparities are less well understood. We modeled sexual orientation disparities in depressive symptoms from late adolescence into young adulthood and evaluated family satisfaction, peer support, cyberbullying victimization, and unmet medical needs as potential mediators.

      METHODS Data were from waves 2 to 6 of the NEXT Generation Health Study (n = 2396), a population-based cohort of US adolescents. We used latent growth models to examine sexual orientation disparities in depressive symptoms in participants aged 17 to 21 years, conduct mediation analyses, and examine sex differences.

      RESULTS Relative to heterosexual adolescents, sexual minority adolescents (those who are attracted to the same or both sexes or are questioning; 6.3% of the weighted sample) consistently reported higher depressive symptoms from 11th grade to 3 years after high school. Mediation analyses indicated that sexual minority adolescents reported lower family satisfaction, greater cyberbullying victimization, and increased likelihood of unmet medical needs, all of which were associated with higher depressive symptoms. The mediating role of cyberbullying victimization was more pronounced among male than female participants.

      CONCLUSIONS Sexual minority adolescents reported higher depressive symptoms than heterosexual adolescents from late adolescence into young adulthood. Collectively, low family satisfaction, cyberbullying victimization, and unmet medical needs accounted for >45% of differences by sexual orientation. Future clinical research is needed to determine if interventions targeting these psychosocial and health care–related factors would reduce sexual orientation disparities in depressive symptoms and the optimal timing of such interventions.

    3. Page 22
      Address correspondence to Laura Baams, PhD, Pedagogics and Educational Sciences, Youth Studies, University of Groningen, Grote Rozenstraat 38, 9712 TJ Groningen, The Netherlands. E-mail: l.baams@rug.nl

      BACKGROUND AND OBJECTIVES Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are suggested to be overrepresented in unstable housing and foster care. In the current study, we assess whether LGBTQ youth are overrepresented in unstable housing and foster care and examine disparities in school functioning, substance use, and mental health for LGBTQ youth versus heterosexual youth in unstable housing and foster care.

      METHODS A total of 895 218 students (10–18 years old) completed the cross-sectional California Healthy Kids Survey from 2013 to 2015. Surveys were administered in 2641 middle and high schools throughout California. Primary outcome measures included school functioning (eg, school climate, absenteeism), substance use, and mental health.

      RESULTS More youth living foster care (30.4%) and unstable housing (25.3%) self-identified as LGBTQ than youth in a nationally representative sample (11.2%). Compared with heterosexual youth and youth in stable housing, LGBTQ youth in unstable housing reported poorer school functioning (Bs = 20.10 to 0.40), higher substance use (Bs = 0.26–0.28), and poorer mental health (odds ratios = 0.73–0.80). LGBTQ youth in foster care reported more fights in school (B = 0.16), victimization (B = 0.10), and mental health problems (odds ratios = 0.82–0.73) compared with LGBTQ youth in stable housing and heterosexual youth in foster care.

      CONCLUSIONS Disparities for LGBTQ youth are exacerbated when they live in foster care or unstable housing. This points to a need for protections for LGBTQ youth in care and care that is affirming of their sexual orientation and gender identity.

    4. Page 31
      Address correspondence to Brian Mustanski, PhD, Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N Michigan Ave, Suite 1400, Chicago, IL 60611. E-mail: brian@northwestern.edu

      BACKGROUND Adolescent men who have sex with men (AMSM) have a high rate of HIV diagnoses. An estimated 14.5% of HIV infections in the United States are undiagnosed; but among 13- to 24-year-olds, the rate is 51.4%. We describe HIV testing rates and identifies salient individual, family, school, and health care influences among AMSM.

      METHODS Data were collected as part of SMART, an ongoing pragmatic trial of an online HIV prevention intervention for AMSM (N = 699). Measures included lifetime HIV testing, demographics, sexual behaviors, condom use, HIV education from school and family, sexual health communication with doctors, HIV knowledge, and risk attitudes.

      RESULTS Only 23.2% of participants had ever had an HIV test. Rates of testing increased with age (5.6% in 13- to 14-year-olds; 15.8% in 15- to 16-year-olds; 37.8% in 17- to 18-year-olds), and sexual experience was a strong predictor of testing (odds ratio: 6.54; 95% confidence interval: 3.95–11.49; P < .001). Most participants had a regular doctor (67.5%), but few had conversations about same-sex sexual behaviors (21.3%), HIV testing (19.2%), or sexual orientation (29.2%). Speaking to a doctor about HIV testing had a large effect (odds ratio: 25.29; confidence interval: 15.91–41.16; P < .001), with 75.4% who had such conversations having been tested, compared to only 10.8% of those who had not had such conversations.

      CONCLUSIONS Despite higher risk, few participants reported ever having received an HIV test. Data indicate pediatricians are an important, but largely untapped, source of testing and could be integral to achieving testing rates needed to end the epidemic.

    5. Page 43
      Address correspondence to Sybil Hosek, PhD, Department of Psychiatry, John Stroger Hospital of Cook County, 1900 W Polk St, Room 655, Chicago, IL 60612. E-mail: shosek@cookcountyhhs.org

      Surveillance data on high school adolescent sexual activity, including teenaged pregnancy rates and incidence of sexually transmitted infections (STIs), require pediatricians and other youth providers to be competent and confident in addressing sexual and reproductive health care needs in adolescent and/or young adult populations. The American Academy of Pediatrics has published guidelines, recommendations, clinical reports, and resources on the promotion of healthy sexual development in clinical settings, encouraging sexual health assessments that are inclusive of HIV and STI testing as an integral component of comprehensive health visits. The need for a more determined effort to address sexual health as it relates to HIV specifically is evidenced by a decrease in the number of in-school youth reporting ever being tested, 15- to 24-year-olds representing 21% of new infections, and estimates that .40% of youth with HIV are undiagnosed. Ending the HIV epidemic requires adherence to published HIV testing recommendations, sexual health assessments, screening for STIs, and appropriate primary and secondary prevention education. Preexposure prophylaxis, an efficacious biomedical prevention intervention for reducing HIV acquisition, was approved in July 2012 and in May 2018 was authorized for use in minors. This state-of-the-art review article provides background information on preexposure prophylaxis, current guidelines and recommendations for use, and strategies to introduce and implement this valuable HIV prevention method in clinical practice with adolescents and young adults.

    6. Page 49

      OBJECTIVES Young women who are sexual minorities (eg, bisexual and lesbian) are approximately twice as likely as those who are heterosexual to have a teen pregnancy. Therefore, we hypothesized that risk factors for teen pregnancy would vary across sexual orientation groups and that other potential risk factors exist that are unique to sexual minorities.

      METHODS We used multivariable log-binomial models gathered from 7120 young women in the longitudinal cohort known as the Growing Up Today Study to examine the following potential teen pregnancy risk factors: childhood maltreatment, bullying victimization and perpetration, and gender nonconformity. Among sexual minorities, we also examined the following: sexual minority developmental milestones, sexual orientation–related stress, sexual minority outness, and lesbian, gay, and bisexual social activity involvement.

      RESULTS Childhood maltreatment and bullying were significant teen pregnancy risk factors among all participants. After adjusting for childhood maltreatment and bullying, the sexual orientation–related teen pregnancy disparities were attenuated; these risk factors explained 45% of the disparity. Among sexual minorities, reaching sexual minority developmental milestones earlier was also associated with an increased teen pregnancy risk.

      CONCLUSIONS The higher teen pregnancy prevalence among sexual minorities compared with heterosexuals in this cohort was partially explained by childhood maltreatment and bullying, which may, in part, stem from sexual orientation–related discrimination. Teen pregnancy prevention efforts that are focused on risk factors more common among young women who are sexual minorities (eg, childhood maltreatment, bullying) can help to reduce the existing sexual orientation–related teen pregnancy disparity.

    7. Page 63

      BACKGROUND Transgender and gender nonconforming (TGNC) adolescents have difficulty accessing and receiving health care compared with cisgender youth, yet research is limited by a reliance on small and nonrepresentative samples. This study’s purpose was to examine mental and physical health characteristics and care utilization between youth who are TGNC and cisgender and across perceived gender expressions within the TGNC sample.

      METHODS Data came from the 2016 Minnesota Student Survey, which consisted of 80 929 students in ninth and 11th grade (n = 2168 TGNC, 2.7%). Students self-reported gender identity, perceived gender expression, 4 health status measures, and 3 care utilization measures. Chi-squares and multiple analysis of covariance tests (controlling for demographic covariates) were used to compare groups.

      RESULTS We found that students who are TGNC reported significantly poorer health, lower rates of preventive health checkups, and more nurse office visits than cisgender youth. For example, 62.1% of youth who are TGNC reported their general health as poor, fair, or good versus very good or excellent, compared with 33.1% of cisgender youth (χ2 = 763.7, P < .001). Among the TGNC sample, those whose gender presentation was perceived as very congruent with their birth-assigned sex were less likely to report poorer health and long-term mental health problems compared with those with other gender presentations.

      CONCLUSIONS Health care utilization differs between TGNC versus cisgender youth and across gender presentations within TGNC youth. With our results, we suggest that health care providers should screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.

    8. Page 73

      BACKGROUND Sexual minority adolescents face mental health disparities relative to heterosexual adolescents. We evaluated temporal changes in US adolescent reported sexual orientation and suicide attempts by sexual orientation.

      METHODS We used Youth Risk Behavioral Surveillance data from 6 states that collected data on sexual orientation identity and 4 states that collected data on sex of sexual contacts continuously between 2009 and 2017. We estimated odds ratios using logistic regression models to evaluate changes in reported sexual orientation identity, sex of consensual sexual contacts, and suicide attempts over time and calculated marginal effects (MEs).

      RESULTS The proportion of adolescents reporting minority sexual orientation identity nearly doubled, from 7.3% in 2009 to 14.3% in 2017 (ME: 0.8 percentage points [pp] per year; 95% confidence interval [CI]: 0.6 to 0.9 pp). The proportion of adolescents reporting any same-sex sexual contact increased by 70%, from 7.7% in 2009 to 13.1% in 2017 (ME: 0.6 pp per year; 95% CI: 0.4 to 0.8 pp). Although suicide attempts declined among students identifying as sexual minorities (ME: –0.8 pp per year; 95% CI: –1.4 to –0.2 pp), these students remained >3 times more likely to attempt suicide relative to heterosexual students in 2017. Sexual minority adolescents accounted for an increasing proportion of all adolescent suicide attempts.

      CONCLUSIONS The proportion of adolescents reporting sexual minority identity and same-sex sexual contacts increased between 2009 and 2017. Disparities in suicide attempts persist. Developing and implementing approaches to reducing sexual minority youth suicide is critically important.

    9. Page 84
      Address correspondence to Richard T. Liu, PhD, Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University and Bradley Hospital, 1011 Veterans Memorial Pkwy, East Providence, RI 02915. E-mail: rtliupsych@gmail.com

      OBJECTIVES In this study, we determined trends in prevalence of suicidal thoughts and behaviors among lesbian, gay, bisexual, and heterosexual youth from 1995 to 2017 using population-based surveillance data.

      METHODS Data were drawn from the Massachusetts Youth Risk Behavior Survey from 1995 to 2017 (unweighted N = 41 636). The annual percent change (APC) in prevalence of suicidal ideation, plans, and attempts was stratified by sexual orientation as indexed by sexual identity and sexual behavior.

      RESULTS Among sexual minority youth, prevalence rates declined over the entire study period for suicidal ideation (APCsexual identity = −1.25; APCsexual behavior = 1.83), plans (APCsexual identity = 1.88; APCsexual behavior = –1.95), and attempts (APCsexual identity =–2.64; APCsexual behavior = –2.47). Among heterosexual youth, prevalence rates declined from 1995 to 2007 for suicidal ideation (APCsexual identity = –6.67; APCsexual behavior = 6.77) and plans (APCsexual identity = –5.73; APCsexual behavior = –6.25). These declines in ideation and plans were steeper than those for sexual minority youth. Prevalence of suicide attempts declined across the entire Study period among heterosexual youth (APCsexual identity = –3.66; APCsexual behavior = –4.01). Prevalence of all 3 outcomes remained markedly high among sexual minority youth across the 23-year study period.

      CONCLUSIONS Although suicidal thoughts and behavior have generally declined among sexual minority and heterosexual youth, disparities in these outcomes persist, and their prevalence among sexual minority youth has remained consistently elevated. Prioritized screening for risk for suicidal thoughts and behaviors in this vulnerable population is imperative to reduce disparities and prevalence of these outcomes.

    10. Page 96
      Address correspondence to Russell B. Toomey, PhD, Department of Family Studies and Human Development, University of Arizona, 650 N. Park Ave, PO Box 210078, Tucson, AZ 85721-0078. E-mail: toomey@email.arizona.edu

      OBJECTIVES Our primary objective was to examine prevalence rates of suicide behavior across 6 gender identity groups: female; male; transgender, male to female; transgender, female to male; transgender, not exclusively male or female; and questioning. Our secondary objective was to examine variability in the associations between key sociodemographic characteristics and suicide behavior across gender identity groups.

      METHODS Data from the Profiles of Student Life: Attitudes and Behaviors survey (N = 120 617 adolescents; ages 11–19 years) were used to achieve our objectives. Data were collected over a 36-month period: June 2012 to May 2015. A dichotomized self-reported lifetime suicide attempts (never versus ever) measure was used. Prevalence statistics were compared across gender identity groups, as were the associations between sociodemographic characteristics (ie, age, parents’ highest level of education, urbanicity, sexual orientation, and race and/or ethnicity) and suicide behavior.

      RESULTS Nearly 14% of adolescents reported a previous suicide attempt; disparities by gender identity in suicide attempts were found. Female to male adolescents reported the highest rate of attempted suicide (50.8%), followed by adolescents who identified as not exclusively male or female (41.8%), male to female adolescents (29.9%), questioning adolescents (27.9%), female adolescents (17.6%), and male adolescents (9.8%). Identifying as nonheterosexual exacerbated the risk for all adolescents except for those who did not exclusively identify as male or female (ie, nonbinary). For transgender adolescents, no other sociodemographic characteristic was associated with suicide attempts.

      CONCLUSIONS Suicide prevention efforts can be enhanced by attending to variability within transgender populations, particularly the heightened risk for female to male and nonbinary transgender adolescents.

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