Talking with Youth about Sexual Orientation and Gender Identity

Age-appropriate conversations about sexual orientation and gender identity with youths and their families by health-care professionals are essential to support the health of all youths and combat mental health disparities, bullying, and higher rates of suicide among LGBTQIA+ youth. As mental health providers, we integrate best practices at the intersection of mental health and pediatrics. We offer strategies for health-care providers to proactively discuss sexual orientation and gender identity and to create a safe place for these discussions.Sexual orientation refers to emotional and/or physical attraction (eg, gay, pansexual), and a youth can endorse multiple sexual orientations. Gender identity is the innate sense of gender (eg, girl, nonbinary). Gender identity is separate from gender expression, such as appearance, clothing, and behavior. Assigned sex refers to the designation the medical profession labels an infant, usually “female” or “male,” based on reproductive anatomy and chromosomes. To promote trust and convey respect for each youth’s identity, it is important to honor the terms youths use to describe their own sexual orientations and gender identities, as these may vary, particularly as language evolves.Discussions can be approached in developmentally appropriate ways along the age spectrum and can include conversations with youth, family and caregivers (ie, parents or guardians), staff at schools, and stakeholders (eg, policymakers, legislators, religious leaders) and other community members (Table). Health-care providers can discuss psychosocial aspects of gender identity and sexual orientation during health supervision visits across the developmental spectrum. In preschool, children may start noticing physical differences across assigned sexes and may explore gender identities expressed by others. Providers can offer psychoeducation using age-appropriate media to normalize exploration of gender expression for children; these discussions can be initiated by providers as part of a regular “preschool” visit by including these as topics of discussion with caregivers (eg, a provider could say to a caregiver, “I always let caregivers know we provide support to families with children who have diverse gender expressions because children who are supported are generally well-adjusted. Is this a topic you feel could be helpful to discuss further?”). Based on a caregiver’s request and/or a child’s presentation, more in-depth supports can be offered. As children enter school-age, providers and caregivers can provide youth psychoeducation on differences across gender identity, gender expression, gender roles, and sexual orientation, as well as inclusive education on puberty. Such discussion can be initiated by providers as part of a regular “school-age” visit in a similar fashion to “preschool” visit discussions. Later, adolescents may actively explore gender identity, sexuality, and sexual behaviors. At this stage, providers can acknowledge that gender identity and sexual orientation may evolve over time and can recommend affirming services, which assert that all identities are valid, and acknowledge oppression. During adolescence and emerging adulthood, providers can support gender-diverse youth and their caregivers by answering questions about medical transition options when requested. When speaking with youths and their families, one should avoid assumptions of identities and pronouns and instead ask patients directly. A particular challenge may be responding to caregivers who are not receptive to their child’s or teen’s sexual orientation or gender. In this situation, a provider can offer validation:Notably, although the previous dialogue example is about a child, it can be adapted for an adolescent. In addition, creating an inclusive environment within health-care settings for these discussions is crucial. One should demonstrate safety in-session by building trust, creating space for youth to share their experiences and discuss challenges, and using a collaborative approach when addressing mental health issues. Indicators that signal safety include 1) introducing oneself with pronouns or wearing a pronoun badge (relatedly, patients report that providers’ selective self-disclosure is validating); 2) using intake questionnaires with inclusive options for sexual orientation and gender identity that do not conflate gender identity with assigned sex; 3) placing LGBTQIA+ books in waiting rooms; 4) providing inclusive play areas that avoid segregating toys by gender; 5) displaying pride flags and LGBTQIA+-affirming artwork in-office; 6) providing pamphlets from LGBTQIA+ organizations such as the Trevor Project or from local centers; 7) educating staff on affirming care; and 8) using medical records with chosen name and pronouns (eg, versus only legal name and assigned sex).It is crucial to educate caregivers and advocate for youth. One should offer support for youth who may want to come out or are facing anti-LGBTQIA+ sentiments from family. Providers are not mandated to disclose the identities a youth discloses to caregivers and should defer to the patient on their preference for what to disclose. This may entail using different names and pronouns for the youth individually versus when referring to the youth with their caregivers or in documentation that caregivers may access. Importantly, forcing disclosure to caregivers may increase risk to youth (eg, assault, being forced out of their home).Challenging conversations can occur with caregivers who experience anxiety around their child being LGBTQIA+ and/or fear medical decisions related to their child’s identities. In these situations, providers can provide space to validate the caregiver’s emotions (eg, grief for their previous relationship and understanding of their child, fear for how systems may discriminate against their child, anger related to difficulty accepting their child’s identities) while providing them psychoeducation on how affirming their child can decrease risk for negative health outcomes and increase positive health outcomes. Providers may also consider offering caregivers referrals for psychotherapy for ongoing support. If questioned about providing affirming care, clinicians can refer to their state licensing board on best practices and provide psychoeducation on best practices to families while providing space to discuss concerns. Providers may discuss affirming care with youth and caregivers together, and may also consider having separate conversations with youth and caregivers to ensure that each have their own space to openly discuss questions and concerns.Advocacy for LGBTQIA+ individuals can include coordinating with schools to facilitate youths’ access to restrooms and sports teams that align with their identities, as well as changing school records of their names and pronouns. Other aspects of advocacy include understanding laws in the clinical practice area that may impact LGBTQIA+ youth. If the clinical practice is in an area where affirmative care for LGBTQIA+ youth is being legally challenged, one should consult with local organizations to identify accessible resources and referrals to support LGBTQIA+ youth and with professional organizations (eg, American Academy of Pediatrics, American Psychiatric Association) for working with LGBTQIA+ youth. One could develop a referral base of LGBTQIA+-affirmative providers by reviewing websites of local practices, engaging with interdisciplinary professional organizations (eg, American Medical Association, American Psychological Association), and becoming familiar with directories of affirmative providers (eg, the World Professional Association for Transgender Health’s member search directory, www.wpath.org/member/search, or the LGBTQ+ Healthcare Directory offered by GLMA: Health Professionals Advancing LGBTQ Equality, glma.org/find_a_provider.php). It is also important to advocate outside of the clinic, which could include voting, consulting local affirming resources within the clinical practice jurisdiction, and staying abreast of laws and policies related to LGBTQIA+ communities to be able to address patient concerns.In summary, it is not only possible but also essential to have age-appropriate conversations about sexual orientation and gender identity. Supporting LGBTQIA+ youth includes providing a safe clinical environment and holding developmentally appropriate discussions on these identities with youth, their caregivers, and their schools and communities.Comments: In our role as advocates for youth, we need to work to eliminate the stigma and discrimination that LGBTQIA+ youth face. This In Brief emphasized several foundational principles. I had never learned about gender diversity and identity during my medical training, so it demonstrates the importance of lifelong learning within our medical profession and also the powerful issue that an individual’s gender identity is now recognized as essential to their health-care and should no longer be kept a secret. It also emphasizes the importance that within the concept of lifelong learning, health-care professionals must embrace and demonstrate humility in acknowledging that we don’t know every term or every concept, but want to learn with the help of and in partnership with our patients. It also reinforces the principle of humanism within medicine, of recognizing and respecting the perspectives of individuals. Attention to humanism can be accomplished at the individual level, with each patient, at their home level by educating their family and caregivers and providing safe spaces for discussion, at the school or community level, and at the state and national levels for all of society. We can strive to understand and eliminate the bullying, stigma, and mental health struggles that these youth experience. Being proactive in identifying whether these issues are relevant to your individual patient and referring to resources that are designed for LGBTQ youth is essential to high-quality care.Janet R. Serwint, MDAssociate Editor, In Brief