Monday, March 13, 2017

Supporting our LGBT adolescents

- Jennifer Middleton, MD

Well care at all stages of life is an important part of many family physicians' practices, but perhaps our visits with adolescents are among the most crucial. Discussing sexual health and risk behaviors in all adolescents can help teens avoid serious health sequelae. These discussions are especially critical for lesbian, gay, bisexual, and transgendered (LGBT) youth, as Drs. Knight and Jarrett remind us in the current issue of AFP.  In their article "Preventive Health Care for Women Who Have Sex with Women" (WSW), they assert that "sexual minority adolescents face unique developmental challenges." Providing a supportive environment for sexual minority youth to discuss their sexuality allows us to provide counseling and care regarding these health concerns.

Adopting gender-neutral language with all of our adolescent patients indicates our willingness to provide a safe space for LGBT youth to tell their story. Asking "Is there someone special in your life?" instead of "Do you have a boyfriend/girlfriend?", for example, avoids assumptions regarding sexual orientation. Confidentiality during adolescent visits is especially important to LGBT teens, who may not have disclosed their sexual identity to family and friends. Protecting confidentiality is appropriate unless the adolescent's safety is immediately at risk (such as disclosure of ongoing abuse or intent to commit suicide). Inquiring about bullying is also a must for LGBT adolescents, as they are at higher risk of peer violence compared to their heterosexual peers. Connecting adolescents, and their families, with organizations such as Parents, Friends, and Families of Lesbians and Gays (PFLAG) and the Gay, Lesbian, and Straight Education Network (GLSEN) may help sexual minority teens find support that may be lacking in school or other social environments.

Establishing rapport and a safe environment allows physicians the opportunity to screen for common adolescent risk-taking behaviors. Drs. Knight and Jarrett discuss the health concerns that are disproportionately increased in adolescent WSW, including eating disorders, depression, social anxiety disorders, sexually transmitted infections (STIs), and substance abuse. Asking specifically about each of these issues can help family physicians uncover risk behaviors and provide counseling and treatment. The authors provide helpful language and prompts for obtaining a sexual and social history in WSW (table 4) along with safer sex recommendations particular to WSW (table 6). You can review counseling recommendations for men who have sex with men (MSM) in this 2015 AFP article; highlights include ensuring that hepatitis and meningitis vaccinations are up to date for MSM who meet criteria and offering pre- and post-exposure prophylaxis when warranted to reduce the risk of human immunodeficiency virus (HIV) infection.

Having awareness of these recommendations and using these techniques as physicians is only a first step; our offices must also reflect our commitment to provide care for all. In an accompanying editorial to Drs. Knight and Jarrett's AFP article, Dr. Stumbar reminds us to "create an inclusive office environment that features photos of same-sex and opposite-sex couples, the rainbow flag, and office staff who are comfortable with nontraditional family structures."  The AFP By Topic on Care of Special Populations includes a subheading on Gay, Lesbian, Bisexual, and Transgendered Persons if you'd like to read more.