Pediatric Primary Care Case Studies (58 page)

   Stress to the patient that sexuality is a very individual thing; that not only are there varying sexual orientations but that even within those, people have their own personal ways of acting that out and that this must be respected and will be respected by you, the healthcare practitioner.

   Encourage her to keep in mind that others are not always as courageous and honest; for example, a bisexual or lesbian woman may be sleeping with a man or using needle drugs and not admit it. Stress that this is why same-sex sexual encounters should even include safe sex between women.

   Ask her what she knows about how to have safer same-sex encounters, where to get the supplies, and specifically how to use them. Tell her that if she should need coaching about how to talk to another woman about using safe sex to please come back and talk with you whenever she needs to.

Adolescents may move through several phases of sexual experimentation before settling on an orientation. In addition, you realize that to speak of this directly at this encounter could give Cassandra the impression that you do not take her current choice seriously. Instead, you decide to ask from the standpoint of a routine STD screening and ask her if she has ever had sex with a male partner and whether it was ever sex without a condom. If she has had unprotected sex with a male, then you might ask her if you can test her today for STDs as part of her routine “well woman” exam.

Sexual Expression of Adolescents

Epidemiology

In 2006, the U.S. Census Bureau, through an American Community Survey, established that there are approximately 21.6 to 21.7 million adolescents of both genders between the ages of 15 and 19. When evaluating the percentage of those who may present in primary care clinics with issues related to gay or lesbian sexual health and accompanying psychosocial issues, social scientists frequently use the rule of thumb that 1 in 10 adolescents is LGBT or otherwise nonheterosexually identified (U.S. Census Bureau, 2006). Closely supporting this estimate, the Kinsey Institute for Sexual Research sponsored a national survey in 2005 that identified nonheterosexual percentages in the American population as 1 in 8 (Kinsey Institute, 2005).

Although it is important to consider that many teens experiment sexually and do not necessarily form a complete sexual orientation until adulthood, a substantial percentage of adolescents who experiment with same-sex partners will eventually identify themselves as gay, lesbian, bisexual, or transgendered. According to the 2005 Kinsey Institute study:

•   Among men ages 18–44, 2.3% considered themselves homosexual, 1.8% identified as bisexual, and 3.9% indicated that they identified as “something else.”

•   Among women between the ages of 18 and 44, 1.3% identified as homosexual, 2.8% considered themselves bisexual, and 3.8% identified as “something else.”

Based on these data, there are at least 2.7 million teens with potential to be involved with same-sex partners around the United States. It is important for healthcare providers to be aware of the needs of this segment of the population, as well as to be prepared to educate and be a source of healthy role modeling for this substantial primary care patient population.

The Kinsey Institute’s (2005) national survey also found that of the teens surveyed, there was about a one in three chance of having engaged in sexual activity with at least one partner at some point in their lives (Kinsey Institute, 2005):

•   
The findings for men of all sexual orientations ages 15–19 years old:
45.1% had not had sexual contact with a partner, 29.7% reported one partner in 12 months, and 21.8% reported two or more partners in the 12-month period. Men in this same age group reported that 2.4% had engaged in same-sex contact in the previous 12 months, and 4.5% had same-sex contact at some point in their history.

•   
The findings for women of all sexual orientations ages 15–19:
42.9% had not had sexual contact with a partner, 30.5% had sexual contact with one partner, and 16.8% had sexual contact with two or more partners in the last 12 months. For women in this same age group, 2.7% reported having engaged in a same-sex contact during the previous 12 months; 7.7% had same-sex contact at some point in their history.

You ask Cassandra if she and this (or any other) female partner have had sexual relations beyond kissing. This will create an opening to ask her what safe-sex practices she knows for woman–woman sex. (If the patient were a male, you would ask what he knows about safe-sex practices for male–male sex.)

What are the risks of contracting a sexually transmitted infection?

STD prevention and identification are factors in the health care and education of all adolescents. Almost half of the 19 million new cases of STDs each year occur among adolescents and young adults between the ages of 15 and 24.

Clinicians need to be able to provide appropriate health screening services and education for LGBT youth in primary care settings because there may be no available resources for LGBT youth within the community that can provide these services in an atmosphere of respect and trust. If the patient fears a breach of confidentiality or feels uncomfortable, she or he may not want to admit having had sexual contact with a same-sex partner or any partner during a health-screening interview. It remains important for providers to anticipate reticence on the part of adolescents, given the epidemiological data available.

Given the level of sexual activity that adolescents in general participate in without proper education and sexual health awareness, there is, as stated earlier, a huge potential for adolescents to become part of the population with what the Centers for Disease Control and Prevention (CDC) terms “widespread” increases. Infections such as herpes, HPV, trichomoniasis and bacterial vaginosis are on the rise, as well as diseases such as chlamydia, especially in areas where screening and treatment are not readily available. STDs such as syphilis, hepatitis B, and chancroid are declining in incidence.

Although the demographics of the lifestyle and needs of LGBT adolescents remain constant in the United States, the provision of health and education services and resources for the LGBT youth population do not. Many communities provide little or nothing to affirm the psychological personhood of LGBT youth, thus passively contributing to depression and suicide. As well, the failure to screen for STDs and to educate this population on health and safer sex practices contributes to the spread of STDs. This is why the primary care provider has such a pivotal role in assisting these teens toward adulthood in a positive, responsible way of living and engaging in healthy, fulfilling, and responsible practices in relationships.

At this point, you can provide Cassandra with available literature, a demonstration of related products such as dental dams, and a gender-specific discussion on how people of alternative lifestyles practice safer sex.

What other areas are important to assess for LGBT youth?

When you have given time in the discussion for Cassandra to think about any other questions or issues she may have related to safe sex, you mention to her that the other part of having a healthy sex life is to be treated respectfully and to treat one’s partner respectfully as well. You let her know that, as her healthcare provider, it is important for you to know whether anyone has ever hurt her or tried to hurt her and how she responded to any incident like this. You tell her that many patients have mentioned this sort of thing and then listen carefully, because if she has ever been abused or disrespected in some way, it may take her time to be able to say it. You ask her if she has thought about hurting herself or hurt herself in the past, and if she is depressed or feeling hopeless or helpless. She clearly says no, so you can move on to the next point.

Depression, Suicide, and Violence

Depression and suicide are among the central health issues associated with gay adolescents. Gay male adolescents are two to three times more likely than their peers to attempt suicide (CDC, 2008). Primary factors in this trend include isolation, domestic abuse, and the lack of role models, which contribute to a profound sense of alienation that then exacerbates the difficulties associated with mainstream adolescence for both boys and girls.

In 1993, the American Academy of Pediatrics’ Committee on Adolescence reported that LGBT youth very often find themselves stigmatized and the recipients of others’ prejudice. They may find themselves in conflict with their families, communities, and schools. If parents react with anger, shock, or guilt upon learning that their child is gay or lesbian, the youth is left to seek understanding and acceptance by others outside of the home. Social and school environments may be even less supportive; gay and lesbian youth have been subject to name calling, ostracizing, or physical abuse. In the face of this rejection, the youth may become isolated, run away, become depressed, or commit suicide. Given such
widespread social difficulty, it is particularly important for healthcare providers to offer a level of openness and acceptance to adolescents struggling with sexual identity. The American Academy of Pediatrics report advises healthcare providers that “. . . 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” (American Academy of Pediatrics, 1993).