Psychosocial Theory

ORIGINAL ARTICLE

Curretit health c&e delivery sites’: Ii,’ are examined, and recommenda- ’ tions are given for improvement of both practitioner skills and health care programs targeting these youth. J Pediatr Health Care. (1997). 11, 266-274.

Psychosocial Issues in Primary Care of

Lesbian, Gay, Bisexual, and

Pansgender Youth

Jennifer L. Kreiss, MN, RN, and

Diana L. Patterson, DSN

T he passage through puberty, peer group acceptance, and the establishment of a personal identity are all developmental

tasks of the adolescent years. For the youth who is lesbian, gay,

bisexual, or transgender, self-acceptance and identity forma-

tion in the face of a heterosexist society are difficult tasks asso-

ciated with many risks to physical, emotional, and social

health. Gay and bisexual males are at particularly high risk for

acquiring sexually transmitted diseases, including human

Jennifer L. Kreiss is a Pediatric Nurse Practitioner at Children’s Hospital & Medical Center in Seattle, Washington.

Diana L. Patterson is an Assistant Professor in Family and Child Nursing at the University of Washington and is Nursing Discipline Head at Adolescent Clinic at the University of Washington in Seattle, Washington.

Reprint requests: Jennifer Kreiss, MN, RN, Children’s Hospital Medical Center, 4800 Sand Point Way NE, P.O. Box 5371, Seattle, WA 98105-0371.

Copyright 0 1997 by the National Association of Pediatric Nurse Associates & Practitioners.

0891.5245/97/$5.00 + 0 25/l/79212

266 November/December 1997

Kreiss & Patterson

immunodeficiency virus and ac- quired immunodeficiency syn- drome (Zenilman, 1988). Lesbian, gay, bisexual, and transgender youth are also at increased risk for low self-esteem, depression, sui- cide (Remafedi, Farrow, & De&her, 1991), substance abuse, school problems, family rejection and dis- cord, running away, homelessness, and prostitution (Kruks, 1991; Remafedi, 1990; Savin-Williams, 1994). The psychosocial health con- cerns faced by sexual minority youth are primarily the result of societal stigma, hatred, hostility, isolation, and alienation (American Academy of Pediatrics Committee on Adolescence, 1993). One of the roles of the primary health care provider is to recognize adoles- cents who are struggling with sex- ual orientation issues and support a healthy passage through the spe- cial challenges of the teen years.

In recent years homosexuality has become increasingly main- stream. Images of lesbians and gay men are visible in every venue of popular culture, from television shows and films to famous sports stars and musicians. Presidential speeches and national debates occur on questions of gays in the military, gay marriage and parent- ing, domestic partnerships, and the acquired immunodeficiency syn- drome epidemic. The heightened public awareness makes it easier for adolescents to recognize the meaning of same-sex attractions and to self-identify as lesbian, gay, bisexual, or transgender (hereafter referred to as LGBT) at younger ages than ever before (Savin- Williams & Rodriguez, 1993). What ,this means for health care pro- viders is that all health histories must include questions about sexu- al preference and practices without making heterosexist assumptions. This is considered standard assess- ment to be covered with all adoles- cent clients.

POPULATION AND PREVALENCE Homosexuality is defined as the persistent sexual and emotional attraction to person(s) of one’s own sex. The American Academy of Pediatrics’ Committee on Ado- lescence (1993) has twice issued a policy statement on homosexuality and adolescence, stating that it is a part of the continuum of sexual expression. Homosexuality is not a mental disorder, nor is it a choice for individuals. The American Psychiatric Association removed homosexuality from its list of men- tal disorders in 1973 (American Academy of Pediatrics’ Committee on Adolescence, 1993). People do not choose to be attracted to per- sons of their own sex, nor can peo- ple choose not to be attracted to persons of their own sex if they are homosexual. Bisexual persons are attracted to both their own and the opposite sex. Transgender persons identify as being members of the opposite of their biologic sex, as, for example, a man who feels that he is actually a woman trapped inside the body of a man. Most transgender persons are biological- ly male but have internalized a female identity. Transgenderism is described in the Diagnostic and Statistical Manual of Mental Dis- orders as a gender identity dis- order (American Psychiatric Asso- ciation, 1994). The incidence of transgenderism in adolescents is unknown but is presumed to be very low because it has not been captured in demographic studies of adolescent sexual orientation. Most research on sexual minority youth does not include transgen- der youth as part of the sample because of the difficulty of finding subjects in this tiny subset of the population. Therefore inclusion of the transgender population when discussing health concerns of sexu- al minority youth is a considered

appraisal of the health needs of a heretofore unstudied group.

Projections of homosexuality in adult men and women range from 1% to 10% (Remafedi, Resnick, Blum, & Harris, 1992). Among ado- lescents, the 1992 survey by Remafedi and colleagues of 35,000 Minnesota junior and senior high school students found that 1.4% described themselves as having a homosexual or bisexual identity. The prevalence of bisexual and homosexual experiences and be- havior was higher than the per- centage of youth who self-identi- fied as gay or bisexual, supporting the idea that many adolescents who experiment with same-sex behavior later identify as hetero- sexual in adulthood. Similarly, 54% of gay males and 81% of lesbians between the ages of 14 and 23 years reported engaging in heterosexual sex. The number of heterosexually and homosexualIy identified ado- lescents who engaged in heterosex- ual sexual behavior was nearly identical, at 65% (Remafedi et al., 1992). Both homosexual and het- erosexual attractions, behaviors, and identities increased with age. Adolescents in general tend to become more sexually active with the increasing physical and emo- tional maturity that accompanies the later teen years.

The age at which youths self- identify as gay or lesbian may be younger today than in previous decades. In the past the average age of self-disclosure of LGBT sex- ual identity to non-gays (i.e., “com- ing out”) has been reported to be in the early to mid 20s. Current re- search shows that age to be falling rapidly, and it is now estimated to be in the late teen years. The younger age of coming out may be attributable to the increased visi- bility of homosexuality in our pop- ular culture (Savin-Williams & Rodriguez, 1993).

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ORIGINAL ARTICLE Kreiss & Patterson

SEXUAL IDENTITY DEVELOPMENT AND THE COMING OUT PROCESS Many gay and lesbian adults say retrospectively that they knew from early childhood that they “felt different” from their peers and that they were able to recognize that their primary attractions were to people of their same sex. Troiden (1988) has constructed a model of individual homosexual identity development (Figure 1). Age pro- gression through the stages of the model varies by individual. Other theorists have expanded on differences in identity develop- ment between gay males and les- bians. Browning (1987) believes that young women develop lesbian identities within a relational con- text and that the establishment of a same-sex intimate relationship en- hances identity formation. Differ- ences have been noted between males and females in the coming- out process (Gonsiorek, 1988). For males the process seems to be more abrupt and more likely to be asso- ciated with symptoms such as de- pression or suicide attempts. For women the process is character- ized by greater fluidity and am- biguity, perhaps because histori- cally women have been allowed a broader range of emotional ex- pression and behavior with other women. Coming out is always an individual choice, and some people never make this choice. Others come out, establish same-sex rela- tionships, and reach the stage of identity commitment while still in their teen years. For youths there is a greater risk of psychosocial problems associated with earlier age of self-identification. Younger youth seem developmentally least equipped to deal with the com- plex social and behavioral con- sequences of acquiring a gay iden- tity (Remafedi, Farrow, & Deisher, 1991). (

49 years oeeurs before puberty

1 2 - 1 8 years 1 5 - 2 2 years adulthood

opment (stages and ages variable).

The coming out process is not solely applicable to the individual. Once the individual discloses an LGBT identity to his or her family, the family faces a not dissimilar process of adaptation to the news. As with individuals, some families choose never to complete or even begin this process of adaptation, and the youth is rejected by the family. It must be pointed out that individuals within the family usu- ally have different time frames for adaptation to the youths disclo- sure, with some individuals mov- ing to an acceptance stage before others. A model of family adapta- tion is shown in Figure 2.

SPECIAL HEALTH CONCERNS Youth who reach the identity as- sumption stage of Troiden’s (1988) model and come out to others dur- ing the teen years have been identi- fied as facing a number of special health challenges. The primary care provider can best assess the needs of LGBT adolescents by con- sidering the concerns frequently encountered by these youth. School problems. Contributing to school difficulties are the friendship loss and peer rejection usually asso- ciated with the disclosure of an LGBT identity to schoolmates. Peer rejection and loss of friends is a dev-

FIGURE 1. Troiden’s model of individual lesbian and gay identity devel-

astating event for the adolescent, whose normal developmental tasks involve a movement away from parents and family and toward the peer group as a growing source of support. Peer group rejection has a powerfully negative effect on the self-esteem and coping of the adolescent. Peers may engage in name-calling and may ridicule, ostracize, or physically abuse the disclosed individual. Youths most abused by peers are those with the most gender-atypical appearance, mannerisms, and behavior. Indi- viduals who failed to incorporate cultural ideals of gender-appropri- ate behavior and roles were most likely to experience peer rejection (Savin-Williams, 1994). Verbal and or physical harassment of the ado- lescent at school along with in- adequate support by teachers and staff contributed to a school drop- out rate of 28% in one study of gay and bisexual boys, with 80% of re- spondents reporting deteriorating school performance (Smith & Mc- Claugherty, 1994). Family conflict and rejection. Pa- rental rejection, at least initially, is a common outcome of youth self-disclosure (Borhek, 1988; Mat- tison & McWhirter, 1995). Families frequently hold antihomosexual attitudes based on homophobia, prejudice, and ignorance. .Family

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ORIGINAL ARTICLE Kreiss & Patterson

INITIAL REJECTION IDENTITY ACCEPTANCE COMMITMENT

youth discloses homosexual *family gradually comes to family able to disclose

identity to family accept youth’s identity (may not son or daughter’s

*homosexuality msy be in conflict extend approval) homosexual identity to

with family’s cultural or religious w-establishment of family others

beliefs communication

wmmon parental reactions are

denial, confusion, guilt, anger,

fear, grief

*initial rejection of youth common

*stage may last months to years

*family-youthcommunication

disrupted

FIGURE 2. Kreiss’ model of family adaptation to a gay son or lesbian daughter (stages of family variable, usually lags behind youth’s development).

difficulties are clearly linked to stigmatization (Herrick & Martin, 1987). Just as individuals struggle with the risks, pain, anguish, and fear of coming out, so must fami- lies face the same emotions when a loved family member discloses a homosexual identity. In the most commonly recognized pattern of coming out, the individual first dis- closes his or her identity to a few carefully chosen friends and only later to family members. Thus by the time a youth comes out to par- ents and family, he or she has already been involved in an in- ternal identity acceptance process that has occurred over months or years. Families may require vary- ing amounts of time to accept the youth’s disclosure. For youth who come out to parents and family before attaining financial indepen- dence, nonsupportive family re- sponses can lead to the youth being ‘thrown out of the home either per- manently or temporarily or to the youth leaving home voluntarily because of isolation, confusion, shame, or family discord. Homelessness. Once a youth is out of the home, an additional set of psychosocial risks is encountered.

Homeless youth face multiple prob- lems including substance abuse, vic- timization by violent hate crimes, conflict with the law, participation in survival sex, poverty and de- creased access to health care ser- vices (Kruks, 1991).

Out-of-home LGBT youth are among the hardest to place of all youth because of their older age at admission to care (adolescents are harder to place than younger chil- dren), a genera1 lack of culturally congruent foster homes, and the difficulty of finding group homes that can incorporate overt sexual minority youth (Sullivan, 1994). Substance abuse. The use of drugs and alcohol is a common coping mechanism of gay-identified youth. Traditionally, one of the few social gathering places for gays and les- bians, both youth and adults, has been in bars. Particularly in rural areas, bars are the only place to see other gay and lesbian people. Alco- hol and drug use among LGBT youth occur at considerably higher rates than the general adolescent population. Nearly 60% of gay and bisexual males in one study were currently abusing substances and met psychiatric criteria for sub-

stance abuse (Savin-Williams, 1994). Substance abuse occurs concurrent to school dropout, homelessness, and criminal activity and is asso- ciated with higher rates of suicide attempts (Remafedi et al., 1991; Savin-Williams, 1994). Depression and suicide. The in- creased incidence of depression and suicide has been well docu- mented for LGBT youth (American Academy of Pediatrics Committee on Adolescence, 1993; Remafedi, 1991; Savin-Williams, 1994; Smith & McClaugherty, 1994). Forty per- cent of homosexual men and women have seriously considered or attempted suicide, with nearly all of the reported attempts occur- ring during the teenage years. Gay adolescents are two to three times more likely to attempt suicide than non-gay peers, and attempts made are more serious and lethal. It is estimated that gay youth account for 30% of completed youth sui- cides each year. LGBT youth of color face a double stigma and have higher rates of suicide at- tempts than white youth. Remafedi and colleagues (1991) reported that one third of first attempts occurred in the first year that subjects identi- fied their homosexuality or bisexu- ality, and most other attempts oc- curred soon thereafter. Compared with LGBT peers, youths who at- tempted suicide recognized same- sex attractions and told others about them at younger ages. At- tempters were also younger at the age of first homosexual experience than peers. For each year’s delay in homosexual self-labeling, the odds of a suicide attempt decreased by 80%. Remafedi and colleagues (1991) concluded that, “Compared with older persons, early and mid- dle adolescents may be generally less able to cope with the isolation and stigma of a homosexual iden- tity” (p. 874). A perspective on health care for LGBT youth. When thinking about provision of health care to LGBT

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ORIGINAL ARTICLE Kreiss & Patterson

BOX 1 Survey of LGBT youth clinics

Method Subjects: Directors of LGBT youth

clinics in the United States Sample size: 5 Measure: Self-administered 21 -item

questionnaire (see appendix) Response rate: 80%

Results

Average age of clients seen: 18.3 years Sexual orientation of clients:

Gay male 50%-97% (average, 70.5%)

Lesbian I%-30% (average, 13%) Bisexual 2%-l 5% (average, 9%)

Access: 100% arrive at clinics on foot/by

bike or by public or private trans- port

Two clinics pick up youths at vari- ous locations and transport them

Funding:* 100% of clinics provide all services

free of charge Two clinics report private and grant

funding

One clinic reports private donations and volunteers

One ciinic reports fundraising and grants

*A// of the clinics providing physical

health care (3 of 4 clinics surveyed)

disagreed that their current funding is adequate to meet their service

goals

Frequency of clinic operation: Average 2.2 times per week Type of health care providers: Medical doctor-l 00% of the three

clinics providing physical health care

Nurse practitioners-66% Physician assistants-33% Nurses-33% Medical assistants-33%

Type of services provided: Minor illness-ne clinic Minor injury-one clinic Sports medicine-one clinic HIV testing-three clinics STD testing/treatment-two clinics Drug/alcohol counseling-two clinics

youth, it is useful to keep the fol- lowing points in mind. One per- cent to 10% of the adult population is homosexual. The average age of homosexual self-definition, based on retrospective studies of adult gays and lesbians, is between 19 and 21 years for males and 21 to 23 years for females (Troiden, 1988). Only after self-definition occurs do individuals begin the process of disclosure to others, known as coming out, which usually occurs over several years during the third decade of life. Therefore of all the people who will eventually dis- close a homosexual identity, less than half will have done so by their twenty-second birthday. Most will come out as adults. This does not mean that youth who have not yet come out are insensitive to hetero- sexist assumptions by health care

providers and others-quite the opposite. The prevalence of the youth’s exposure to these assump- tions may be a contributing factor to the youth’s delay in attaining identity assumption. Health care providers cannot know which of the youth they see may one day self-identify as LGBT; thus gender- neutral language and avoidance of gender stereotypes and heterosex- ist assumptions for all persons seen in the clinical setting are important.

CURRENT HEALTH CARE DELIVERY TO LGBT YOUTH Survey of LGBT Youth Health Clin- ics. The authors conducted a study of health clinics specifically target- ing the LGBT youth population. The purpose of the study was to (a) identify clinics currently serving LGBT youth and (b) evaluate the

effectiveness of the clinics currently in existence (Box 1).

Currently only four major metro- politan cities have clinics specifical- ly designed to meet the health needs of LGBT youth. Cities with specialized LGBT youth clinics are Seattle, Minneapolis, Los Angeles, and New York. Other metropolitan areas (Boston, Chicago, San Fran- cisco, and Washington, D.C.) have LGBT youth centers that coordi- nate referrals to health services familiar with LGBT youth issues. The self-described mission of the health clinics varies in focus, from “human immunodeficiency virus prevention and treatment” to “safe supportive space” to “provision of culturally sensitive care.” Special- ized metropolitan free clinics ad- dress the need for affordable, acces- sible, culturally congruent services in areas with significant popula- tions of high-risk urban LGBT youth, many of whom have multi- ple risk factors including poverty, homelessness, substance abuse, and positive human immunodefi- ciency virus status. However, most of the health services needs of LGBT youth can be provided in general adolescent health care set- tings by a primary care provider who is familiar with adolescent issues, sexual health, LGBT specific issues, and community resources for LGBT youth (Box 2). Survey of LGBT Youth Regarding Quality of Health Care Received. Blanc0 (1995) surveyed LGBT youth in Washington State to assess their access to health care and the quality of care they received. The study found that 66% of youth stat- ed that their health provider had never brought up issues of sexual orientation. Many received inap- propriate treatment and health ed- ucation based on their provider’s heterosexual assumption and igno- rance of their true sexual orienta- tion. The youth also rated health care provider qualities that were important to them. Most important

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BOX 2 Coordination of care for LGBT youth content referral I ist

l Peer support groups (gay, les- bian, transgender, youth of color, HIV+)

l Counseling (individual and family)

l Emergency housing l Food assistance l Clothing assistance l Drug and alcohol recovery ser-

vices l Legal assistance l Education programs l Job training l Prostitution diversion

to youth were that the provider be skilled, be supportive of the youth’s sexual orientation, be the same sex as the youth, and share the same sexual orientation. Other considerations were the provider’s age and ethnic background, with youth preferring providers that were most like themselves. Overcoming Barriers to Care De- livery. Practitioners working with teens must address access issues relevant to all adolescent health care. Services must be available, visible, affordable, flexible, confi- dential, coordinated, and of high quality (Society for Adolescent Medicine, 1992). Many LGBT youth fear that the provider will tell their parents about their sexual identity; therefore health care providers should inform the youth what in- formation can and will be kept con- fidential. Also, practitioners should have LGBT resources to offer teens and keep lists updated as new ser- vices become available. In addition, providers must keep their knowl- edge current on issues affecting the LGBT community including legis- lation and health and actively dis- pel myths and correct stereotypes with clients and families. Providers

can advertise their services in gay and lesbian publications and at meeting places to encourage youth to seek them out as a provider. Many youth have difficulty making and keeping appointments; drop-in hours can add to the clinic’s flexibil- ity. Barriers such as lack of trans- portation can be addressed by of- fering bus tokens or coordinating with other local youth services to provide a van service. A system- atic outreach strategy is necessary to bring adolescents into care. Ex- amining barriers related to both LGBT adolescents (client barriers) and to the particular care setting (institutional barriers) can result in better access to care for this at-risk population (Dilorenzo et al., 1993). Institutional barriers include rais- ing provider awareness of LGBT is- sues, support for ongoing provider training, solicitation of community support for the clinic’s mission and service goals, and adequate clinic funding to provide cost-effective yet comprehensive service.

ROLE OF THE PRIMARY HEALTH CARE PROVIDER The goal of health care provision to LGBT youth is to provide care sen- sitive to the unique needs of this population within a safe, accept- ing, and supportive environment. To achieve this goal providers must first, create a safe space for youth to seek health care, second, incorpo- rate knowledge of LGBT health issues into designing a care plan unique to the needs of the youth, and third, coordinate comprehen- sive service delivery (Box 3). Creating a Safe Space for Care. Prac- titioners working with children can start early to create a safe, trusting, and unbiased setting for care deliv- ery. With only gender-neutral lan- guage in history-taking and the avoidance of gender stereotyping, practitioners never assume any cli- ent is heterosexual including and especially children and adolecents, who have yet to define their sexual

BOX 3 The role of the pediatric nurse practitioner in provision of health care services for LGBT youth

l Health promotion * Complete assessment * Minor illness care l Minor injury care l Sports health care l Dental care referral l Mental health screening and

referral l STD testing and treatment l HIV testing, including partner

testing l Risk reduction counseling l Barriers and contraceptives l Drug/alcohol counseling l Crisis intervention

preference. Total avoidance of het- erosexual assumptions during con- versation with youth is a cue to them that the provider is aware of nonheterosexual options. For exam- ple, few teenage lesbians will bother to correct the practitioner who asks only whether they have a boy- friend; the question will only add to the sense of isolation and different- ness the teen already feels. The key to quality service delivery for LGBT youth is to ask the right questions and to assess the known risk areas of LGBT youth (Table). Health care providers must assess their client’s sexual preferences and practices to give appropriate treatment and ed- ucation. A relaxed attitude about sexual development and an open- ness to exploring issues of sexuality with youth are essential for build- ing the trust it will take for a youth to discuss such personal matters with the health care provider.

Practitioners must be prepared to articulate their philosophy of sexu- al health care to parents, explaining their use of gender-neutral lan- guage and conscious avoidance of gender stereotypes. Practitioners

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‘34 ORIGINAL ARTICLE Kreiss & Patterson

TABLE Psychosocial interventions for gay, lesbian, bisexual and transgender youth: A clinical path

Timeline: Initial Visit

Functional health pattern Outcomes Assessment Intervention/Referral

Coping/stress tolerance

1. Adolescent recognizes that heterosexuality, homosexuality, and bisexuality are all nor- mal expressions, and all can be practiced within the context of healthy, normal lives

2. Adolescent can identify sources of stress

3. Adolescent effectively manages stress through use of coping techniques that promote health, growth and develop- ment

4. Adolescent can identify resources to assist in coping/stress reduction

Roles/relation- ships

1. Adolescent has the abil- ity and opportunity to form healthy relation- ships with family, peers, and community

Sexuality 1. Adolescent develops positive feelings and ex- periences satisfaction re- garding sexual identity

2. Adolescent demon- strates responsible deci- sion-making re: sexual behavior and health

1. Assess stereotypic ideas and attitudes

2. Assess adolescent’s internal concerns re: l Comfort with perceived

identity l Comfort in communicating

sexual-preference concerns with health provider

3. Assess degree of isolation 4. Assess evidence of depression,

i.e. social withdrawal, declin- ing school performance, sub- stance abuse, disrupted family relationships, runaway behav- ior, health risk-taking (unsafe sex, promiscuity, self-harm, suicide ideation)

1. Assess adolescent’s external concerns re: l Family relationships and

family member’s knowledge of sexual-orientation issues

l Interaction at school/job . Peer friendships and peer

knowledge of sexual orienta- tion

l Community involvement

1. Assess concerns re: l Sexual experiences and

practices l Experiences with uncomfort-

able touch or abuse 2. Assess awareness of options

related to sexual activity, knowledge of reproduction, disease transmission, and con- traception/barrier methods

Interventions: l Assure confidentiality l Be supportive and nonjudgemental l Avoid labels by discussing the spec-

trum of sexual orientation l Provide accurate and unbiased infor-

mation-correct stereotypes l Allow time for self-definition l Validate homosexual, heterosexual,

and bisexual behaviors as compatible with a healthy, normal life

l Assist in identifying stressors and exploring coping strategies

. Teach a variety of coping strategies l Provide sources of information and

support (keep a complete referral list of gay and lesbian resources for your area)

Referrals: 9 Youth LGBT support groups if youth

desires for evidence of depression, refer to mental health counseling

Interventions: l Assist youth to identify supportive

adult(s) l Assist youth to identify supportive fam-

ily member(s) (explore extended family if necessary)

l Assist youth to identify supportive peer(s)

l Assist youth to identify supportive community (i.e., youth groups/youth centers/gathering places, books, news- papers, internet resources)

interventions: l Provide unconditional acceptance of

the youth l Validate sexual preference as legiti-

mate l Explore sexual decision-making and

assertiveness techniques l Teach facts about safer sex practices,

disease transmission, reproductive bar- rier/contraceptive choices

Referrals: l Refer to counseling for unresolved

abuse issues

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Kreiss & Patterson

TABLE Psychosocial interventions for gay, lesbian, bisexual and transgender youth: A clinical path-confti

Timeline: Follow-up visit(s)-Two weeks to two months depending on risk profile

Functional health pattern Outcomes Assessment Intervention/Referral

Coping/stress tolerance

1. Adolescent can begin to verbalize own process of self-acceptance

2. Adolescent begins to effectively manage stress through use of coping techniques that promote health, growth and development

Roles/relation- ships

1. Adolescent has the abili- ty and opportunity to form healthy relation- ships with family, peers and community

2. Adolescent can identify supportive adult(s), fami- ly member(s), peer(s) and has knowledge of available community resources

Sexuality 1. Adolescent begins to develop positive feelings and verbalizes accep- tance of sexual identity of self and others

2. Adolescent begins to demonstrate responsible decision-making regard- ing sexual decision- making and sexual health

1. Assess level of identity devel- opment (seeTroiden, 1988), i.e., sensitization, identity con- fusion, identity assumption, commitment

2. Assess coping techniques for identified current stressors

3. Assess whether stressors ex- ceed current coping strategies

1. Assess supportive and nonsup- portive factors in current rela- tionships

1. Continue ongoing assessment of feelings, experiences, and values regarding own sexuality and that of others

2. Assess sexual knowledge and behavior

Interventions: l Assist youth to identify own goals for

personal physical and mental health l Validate the youth’s process of identity

development, emphasizing that indi- vidual timelines for acceptance vary, that individual timelines for accep- tance vary, and that the process is life- long

l Assist in identifying coping strategies Referrals: 9 Suggest appropriate community \

resources for support (see referral list in Box 2)

Interventions: * Assist in identifying and improving

supportive relationships * Offer to meet with parents/family to

facilitate family communication Referrals: l Individual counseling l Family counseling (referrals to counsel-

ing agencies with philosophical con- gruence to youth and family)

Interventions: l Validate the individual and his/her

feelings l Validate the youth’s experience 9 Identify progress the youth is making

toward achieving safe, satisfying rela- tionships

* Assist in problem-solving ways to make the youth‘s experiences healthier and/or more satisfying

l Reinforce teaching of disease transmis- sion and risk-reduction techniques

can explain the spectrum of sexual orientation to families. As a pri- mary care provider, speak openly and matter-of-factly about sexual health, incorporating age-appro- priate discussion into al1 well-child visits. “Creating a safe space” also entails such efforts as having gay

and lesbian books on your shelf and fliers on your wall. It includes having office staff and colleagues who are comfortable, friendly, and accepting of LGBT youth in the care setting.

The pediatric nurse practitioner can be an ideal care provider for

this population and can function in the role of case manager to ensure appropriate, comprehensive, and cost-effective care delivery. It is the role of the practitioner to provide accurate, unbiased information, support, resources, and uncondi- tional acceptance. It is not the role

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ORIGINAL ARTICLE Kreiss & Patterson

of the practitioner to “diagnose” sexual orientation; sexual orienta- tion is not a disease to diagnose. Nor is it the practitioner’s role to encourage the youth to come out to self or others; only the adolescent can decide what his or her sexual orientation is and both when and how much of that information will be shared with others. The Table is an example of a clinical path based on selected functional health pat- terns particularly relevant to the health care of LGBT youth. Steps to a Healthy Future. With in- creasing visibility of LGBT persons in our communities and an ongo- ing societal dialogue regarding gay and lesbian issues, the shame and stigma of being lesbian, gay, bisex- ual, or transgender in our society is decreasing. A better awareness on the part of health care providers of LGBT youth health issues will im- prove the quality of services of- fered and may improve the health status of LGBT youth. With the growing acceptance of all types of sexual expression as compatible with a healthy lifestyle, an increase in the quality and availability of appropriate health services for LGBT youth is now both a reason- able expectation and a goal for both the present and near future. Health care providers acting as youth ad- vocates in the health care and legal arenas can make a positive con- tribution to achieving this goal. Homosexuals are among the last groups in our society to still suffer legal discrimination. The support of equal rights and antidiscrimina- tion legislation for all people will

ease the burden of stigma and help the young people of today to be- come healthy, contributing mem- bers of society.

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