This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years by the authoring body, at which time a recommendation is made that the policy be retired, revised, or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation, or retires a statement, the current policy remains in effect.

Health concerns and risks associated with sexual orientation, including mental health problems and sexually transmitted diseases

Counseling
Prevention

Family Practice
Pediatrics
Psychiatry
Psychology

Health Care Providers
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers

To provide appropriate recommendations to promote normal adolescent development, social and emotional well-being, and physical health in youth who are or think they might be gay, lesbian, or bisexual

Youth who are or think they might be gay, lesbian, or bisexual

Counseling on Sexual Orientation in Adolescents

1. Appropriate office practice
2. Protection of confidentiality
3. Use of appropriate language
4. Provision of educational materials
5. Use of gender neutral language
6. Discussion of risks associate with sexual activity
7. Screening for sexually transmitted diseases
8. Identification of mental health concerns

Not stated

Searches of Electronic Databases

Not stated

Not stated

Not stated

Not applicable

Review

Not stated

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

Office Practice: Ensure a Safe and Supportive Environment

A pediatric encounter may give adolescents a rare opportunity to discuss their concerns about their sexual orientation and/or activities. Adolescents’ level of comfort in the pediatric office sets the tone for their other health care interactions. The way sexuality and other important personal issues are discussed also sets an example for all adolescents and their parents. In the office, pediatricians are encouraged to:

1. Assure the patient that his or her confidentiality is protected.
2. Implement policies against insensitive or inappropriate jokes and remarks by office staff.
3. Be sure that information forms use gender-neutral, nonjudgmental language.
4. Consider displaying posters, brochures, and information on bulletin boards that demonstrate support of issues important to nonheterosexual youth and their families (e.g., the American Academy of Pediatrics [AAP] brochure "Gay, Lesbian, and Bisexual Teens: Facts for Teens and their Parents").
5. Provide information about support groups and other resources to nonheterosexual youth and their friends and families if requested.

Comprehensive Health Care for All Adolescents

Pediatricians are not responsible for labeling or even identifying nonheterosexual youth. Instead, the pediatrician should create a clinical environment in which clear messages are given that sensitive personal issues including sexual orientation can be discussed whenever the adolescent feels ready to do so. A major obstacle to effective medical care is adolescents’ misunderstanding of their right to confidential care. The pediatrician should be ready to raise and discuss issues of sexual orientation with all adolescents, particularly those in distress or engaged in high-risk behaviors. The pediatrician should be able to explore the adolescent’s understanding and concerns about sexual orientation, dispel any misconceptions, provide appropriate medical care and anticipatory guidance, and connect the adolescent to appropriate supportive community resources. Pediatricians are encouraged to:

1. Be aware of the special issues surrounding the development of sexual orientation.
2. Assure the patient that his or her confidentiality is protected.
3. Discuss emerging sexuality with all adolescents.
   • Be knowledgeable that many heterosexual youth also may have sexual experiences with people of their own sex. Labeling as homosexual an adolescent who has had sexual experiences with persons of the same sex or is questioning his or her sexual orientation could be premature, inappropriate, and counterproductive.
   • Use gender-neutral language in discussing sexuality; use the word "partner" rather than "boyfriend" or "girlfriend," and talk about "protection" rather than just "birth control."
   • Give evidence of support and acceptance to adolescents questioning their sexual orientation.
   • Provide information and resources regarding gay, lesbian, and bisexual issues to all interested adolescents.
   • Ask all adolescents about risky behaviors, depression, and suicidal thoughts.
   • Encourage abstinence, discourage multiple partners, and provide "safer sex" guidelines to all adolescents. Discuss the risks associated with anal intercourse for those who choose to engage in this behavior, and teach them ways to decrease risk.
   • Counsel all adolescents about the link between substance use (alcohol, marijuana, and other drugs) and unsafe sexual intercourse.
   • Ask all adolescents about personal experience with violence including sexual or intimate-partner violence. Provide additional screening and education as indicated for each adolescent’s sexual activity:
     • Sexually transmitted disease (STD) testing from appropriate sites
     • Human immunodeficiency virus (HIV) testing with appropriate support and counseling
     • Pregnancy testing and counseling
     • Papanicolaou testing
     • Hepatitis B and, when appropriate, hepatitis A immunization

4. Ensure that colleagues to whom adolescents are referred or with whom you consult are respectful of the range of adolescents’ sexual orientation.

Special Considerations for Nonheterosexual Youth

For adolescents who self-identify as gay, lesbian, or bisexual, pediatricians should be particularly aware of several points:

1. Be prepared to refer adolescents’ care if you have personal barriers to providing such care. Many individuals have strong negative attitudes about homosexuality or may simply feel uncomfortable with the subject. Even discomfort expressed through body language can send a very damaging message to nonheterosexual youth. It is an ethical and professional obligation to make an appropriate referral in these situations for the good of the child or adolescent.
2. Assure the patient that his or her confidentiality is protected. Discuss with adolescents and, if appropriate, their parents whether they wish to have their sexual orientation recorded in office and hospital charts. Many nonheterosexual adults prefer to have this information recorded so that health care professionals will not assume heterosexuality.
3. Help the adolescent think through his or her feelings carefully; strong same-sex feelings and even sexual experiences can occur at this age and do not define sexual orientation.
4. Carefully identify all risky behaviors (sexual behaviors; use of tobacco, alcohol, and drugs; etc.) and offer advice and treatment if indicated.
5. Ask about mental health concerns and evaluate or refer patients with identified problems.
6. Offer support and advice to adolescents faced with or anticipating conflicts with families and/or friends.
7. Encourage transition to adult health care when age-appropriate.

Pediatricians should be aware that the revelation of an adolescent’s homosexuality (also called disclosure or "coming out") has the potential for intense family discord. In many families, it precipitates physical and/or emotional abuse or even expulsion. The pediatrician can advise the adolescent to use certain language that may be helpful at the time of disclosure, such as "I am the same person; you just know one more thing about me now." However, there is no one disclosure technique that will preclude negative reactions. Parents, siblings, and other family members may require professional help to deal with their confusion, anger, guilt, and feelings of loss, and professionals who work with adolescents may be required to intervene on the adolescent’s behalf. If the pediatrician has a relationship with the parents from ongoing primary care, he or she can be an important initial source of support and information. However, adolescents should be counseled to think carefully about the consequences of disclosure and to take their time in sharing information that could have many repercussions.

With regard to parents of nonheterosexual adolescents, pediatricians are encouraged to:

1. Advise adolescents about whether, when, and how to disclose their nonheterosexuality to their parents. If unsure, assist the adolescent in finding a knowledgeable professional who can help.
2. Be knowledgeable about the process of disclosure.
3. Be supportive of parents of adolescents who have disclosed that they are not heterosexual. Most states have chapters of Parents and Friends of Lesbians and Gays (PFLAG) to which interested families may be referred.
4. Remind parents and adolescents that gay and lesbian individuals can be successful parents themselves.
5. Be prepared to refer parents if you do not feel personally comfortable accepting this responsibility.

Community Advocacy

Some pediatricians may wish to take a broader role in their communities to help decrease these risks. Pediatricians could model and provide opportunities for increasing awareness and knowledge of homosexuality and bisexuality among school staff, mental health professionals, and other community leaders. They can make themselves available as resources for community HIV and acquired immunodeficiency syndrome (AIDS) education and prevention activities. It is critical that schools find a way to create safe and supportive environments for students who are or wonder about being nonheterosexual or who have a parent or other family member who is nonheterosexual. Support from respected pediatricians can facilitate these efforts greatly. Pediatricians who choose to be active on these issues may wish to:

1. Help raise awareness among school and community leaders of issues relevant to nonheterosexual youth.
2. Help with the discussion of when and how factual materials about sexual orientation should be included in school curricula and in school and community libraries.
3. Support the development and maintenance of school- and community-based support groups for nonheterosexual students and their friends and parents.
4. Support HIV and AIDS prevention and education efforts.
5. Develop and/or request continuing education opportunities for health care professionals related to issues of sexual orientation, nonheterosexual youth, and their families.

Summary of Physician Guidelines

The American Academy of Pediatrics reaffirms the physician’s responsibility to provide comprehensive health care and guidance in a safe and supportive environment for all adolescents, including nonheterosexual adolescents and young people struggling with issues of sexual orientation. Some pediatricians might choose to assume the additional role of advocating for nonheterosexual youth and their families in their communities. The deadly consequences of HIV and AIDS, the damaging effects of violence and ostracism, and the increased prevalence of adolescent suicidal behavior underscore the critical need to address and seek to prevent the major physical and mental health problems that confront nonheterosexual youths in their transition to a healthy adulthood.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Promotion of normal adolescent development, social and emotional well-being, and physical health in youth who are or think they might be gay, lesbian, or bisexual

Not stated

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

An implementation strategy was not provided.

Staying Healthy

Patient-centeredness

Not applicable: The guideline was not adapted from another source.

2004 Jun

American Academy of Pediatrics - Medical Specialty Society

American Academy of Pediatrics

Committee on Adolescence

Committee on Adolescence, 2002–2003: David W. Kaplan, MD, MPH, Chairperson; Angela Diaz, MD; Ronald A. Feinstein, MD; Martin M. Fisher, MD; Jonathan D. Klein, MD, MPH; W. Samuel Yancy, MD

Past Committee Members: Luis F. Olmedo, MD; Ellen S. Rome, MD, MPH

Liaisons: S. Paige Hertweck, MD, American College of Obstetricians and Gynecologists; Glen Pearson, MD, American Academy of Child and Adolescent Psychiatry; Miriam E. Kaufman, MD, Canadian Paediatric Society; Barbara L. Frankowski, MD, MPH, Past Liaison to Section on School Health; Diane G. Sacks, MD, Past Liaison From Canadian Paediatric Society

Consultant: Ellen C. Perrin, MD

Staff: Karen S. Smith

Not stated

This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years by the authoring body, at which time a recommendation is made that the policy be retired, revised, or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation, or retires a statement, the current policy remains in effect.

None available

None available

This NGC summary was completed by ECRI on August 10, 2004. The information was verified by the guideline developer on September 27, 2004.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest Point Blvd, Elk Grove Village, IL 60007.