1. David J. Breland MD MPH Assistant Professor of Pediatrics Seattle Children’s Hospital University of Washington

2. I do not have any conflict of interest

3. By the end of this presentation, participants will be able to: Identify three risk factors faced by LGBTQ youth. Discuss the ways that homophobia contributes to LGBTQ health outcomes. List three elements of LGBTQ competent healthcare delivery.

4. Sexual development and growth is a natural part of human development Healthy sexual expression is different than sexual risk Same-sex sexual behavior is included in the realm of healthy sexuality

5. Many LGBTQ teens lead normal, productive lives Usually develop resilient adaptations to social biases and mistreatment Many develop and possess remarkable strength and self-determination

6. Youth may internalize societal homophobia leading to: Decreased sense of self-worth Self-medication and substance abuse Shame Risk-taking behavior Suicidality

7. Perceived lack of confidentiality Fear of healthcare provider reaction upon disclosure Provider’s assumption of heterosexuality Internalized shame guilt

8. Train all staff Assure Confidentialit y Display LGBTQ affirming materials Provide support resources Zero tolerance for insensitivity

9. Understand personal biases Provider discomfort can be damaging It is an ethical obligation to refer patient for appropriate care

10. Sexual Attraction Sexual Attraction Paradigm of Sexuality Biological Sex Biological Sex Sexual Orientation Sexual Orientation Sexual Behavior Sexual Behavior Gender Identity/ Expression Gender Identity/ Expression What is gender identity? Personal conception of oneself as male or female What is gender identity? Personal conception of oneself as male or female

11. Gender Identity/ Expression Gender Identity/ Expression Biological sex does not always match gender identity

12. Natal Sex/Anatomy Male Gender Identity Feminine Male Gender Expression Female Masculine HeterosexualHomosexual Sexual Orientation

13. Transition  Process and time when person goes from living as one gender to living as another gender Identities include but are not limited to: MTF=male to female, transgender woman FTM=female to male, transgender man

14. Approaching Gender Identity Ask: When you think of yourself as a person, do you think of yourself as male, female, both, or another gender?

15. Refers to an individual’s pattern of physical and emotional arousal toward other people Heterosexual Homosexual—gay and lesbian Bisexual Pansexual Queer Other

16. Most LGBTQ youth are “invisible” and often will not raise issue until asked Asking normalizes notion that there is a range of sexual orientations and gender identities

18. 11% 22% 33% 55%

19. 12% 22% 32% 52%

20. 7% 17% 37% 57%

21. How can you respectfully ask about sexual orientation? Are you sexually attracted to guys, girls, or both? When you think of yourself in a relationship is it with a guy, a girl, or both?

22. Assess comfort with feelings Identify to whom (if anyone) the patient has disclosed the information Counsel regarding consequences of disclosure to family, friends, etc. Discuss ways to facilitate communication with parents

23. Gender Identity and orientation can be confusing Orientation does not always = behavior Majority of women who have sex with women (53–99%) have had sex with men

24. Young women who identified themselves as “unsure” of their sexual orientation are: Almost twice as likely to report no contraceptive use at last sex

25. When compared to heterosexual youth, lesbians and bisexuals: Are about as likely to have had intercourse Experience twice the rate of pregnancy (12% vs. 6%) Are more likely to have had two or more pregnancies (23.5% vs. 9.8%)

26. Increased Risks: Trichomonas HPV Bacterial vaginosis HIV Nationwide study of 6,935 self-identified lesbians: 17.2% reported a past history of an STI

27. Sex toys Do not share insertive sex toys without a condom Wash sex toys after each use Dental dam use with oral sex Condom use when having sex with a male

28. Family discord and rejection Religious condemnation School and peer problems Physical violence Social stigma Isolation Homelessness

29. 2–7 times more likely to attempt suicide ~2 times as likely to report depression Young MSM are more likely to suffer body image dissatisfaction and disordered eating behaviors

30. 28% drop out of school due to harassment 25–40% of homeless youth may be LGBTQ Increased risk of bullying and harassment 84% report verbal harassment 30% report being punched, kicked, or injured 55% of trans youth report physical attacks

31. In the last 30 days, LGBTQ youth are more likely to have used: Tobacco (59.3% vs. 35.2%) Alcohol (89.4% vs. 52.8%) Cocaine (25.3% vs. 2.7%) LGBTQ youth are more likely to have used substances <the age of 13: Tobacco (47.9% vs. 23.4%) Alcohol (59.1% vs. 30.4%) Cocaine (17.3% vs. 1.2%)

32. Pap and Chlamydia screening under the same guidelines routine for all women Routine screenings not recommended, but note that WSW may be at risk for: Trichomonas Bacterial Vaginosis HSV HPV HIV

33. Syphilis Test for: Urethral test with N. gonorrhoeae and C. trachomatis Rectal infection with N. gonorrhoeae and C. trachomatis Pharyngeal infection with N. gonorrhoeae

34. Among young men who have sex with men (YMSM) 27%–48% have engaged in unprotected anal sex <6 months before

35. Withhold judgment Respect concerns Listen to concerns of discomfort or sizing issues Offer a wide range of condoms including larger sizes and different colors

36. Can you: Identify three risk factors faced by LGBTQ youth Discuss the ways that homophobia contributes to LGBTQ health outcomes List three elements of LGBTQ competent healthcare delivery

37. Resources: www.prch.org—Physicians for Reproductive Choice and Health www.prch.org www.glma.org—Gay and Lesbian Medical Association www.glma.org www.aap.org—The American Academy of Pediatrics www.aap.org www.acog.org—The American College of Obstetricians and Gynecologists www.acog.org www.adolescenthealth.org—The Society for Adolescent Health and Medicine www.adolescenthealth.org http://www.aclu.org/reproductiverights—The Reproductive Freedom Project of the American Civil Liberties Union http://www.aclu.org/reproductiverights www.advocatesforyouth.org—Advocates for Youth www.advocatesforyouth.org www.guttmacher.org—Guttmacher Institute www.guttmacher.org www.cahl.org—Center for Adolescent Health and the Law www.cahl.org http://janefondacenter.emory.edu/—The Jane Fonda Center of Emory University http://janefondacenter.emory.edu/ www.siecus.org—The Sexuality Information and Education Council of the United States www.siecus.org www.arhp.org—The Association of Reproductive Health Professionals www.arhp.org

38. www.pflag.org—Parents and Friends of Lesbians and Gays www.pflag.org familyproject.sfsu.edu—Family Acceptance Project familyproject.sfsu.edu

39. Lambert House: www.lamberthouse.org/ www.lamberthouse.org/ Ingersoll Gender Center: www.ingersollcenter.org/ www.ingersollcenter.org/ Center of Excellence for Transgender Health: http://transhealth.ucsf.edu/ http://transhealth.ucsf.edu/ Gay and Lesbian Medical Association: www.glma.orgwww.glma.org World Professional Association for Transgender Health www.wpath.org/index.cfm www.wpath.org/index.cfm National Center for Transgender Equality: www.nctequality.orgwww.nctequality.org Transgender Law Center: www.transgenderlawcenter.orgwww.transgenderlawcenter.org