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## Complete Summary

#### GUIDELINE TITLE

Sexual orientation and adolescents.

#### BIBLIOGRAPHIC SOURCE(S)

Frankowski BL. Sexual orientation and adolescents. Pediatrics 2004
Jun;113(6):1827-32. \[43 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15173519)

#### GUIDELINE STATUS

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.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

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

#### GUIDELINE CATEGORY

Counseling\
Prevention

#### CLINICAL SPECIALTY

Family Practice\
Pediatrics\
Psychiatry\
Psychology

#### INTENDED USERS

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

#### GUIDELINE OBJECTIVE(S)

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

#### TARGET POPULATION

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

#### INTERVENTIONS AND PRACTICES CONSIDERED

**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

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

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

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**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

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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.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

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

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Frankowski BL. Sexual orientation and adolescents. Pediatrics 2004
Jun;113(6):1827-32. \[43 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15173519)

#### ADAPTATION

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

#### DATE RELEASED

2004 Jun

#### GUIDELINE DEVELOPER(S)

American Academy of Pediatrics - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Pediatrics

#### GUIDELINE COMMITTEE

Committee on Adolescence

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*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

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

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.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Academy of Pediatrics
(AAP) Publications Web
site](http://aappolicy.aappublications.org/cgi/content/full/pediatrics;113/6/1827).

Print copies: Available from American Academy of Pediatrics, 141
Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009-0927.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

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

#### COPYRIGHT STATEMENT

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.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008