Gay, Lesbian, and Bisexual Adolescents

Understanding a child's or adolescent's sexual and emotional development is an essential part of any comprehensive pediatric evaluation. For youth who are or might be gay, lesbian, or bisexual ( GLB ), such understanding is particularly important. GLB youth as a group have the same health and developmental needs as all youth, and their sexual orientation is part of the spectrum of human sexuality. However, they encounter distinct developmental challenges and can have additional physical and mental health needs related to their orientation and others’ reaction to it. Their sexual orientation is often different from that expected by family, peers, and society (although expectations have been changing in many contexts), and they must cope with peer rejection, bullying, or family nonacceptance more frequently than most youth. Although the majority of GLB adolescents grow up physically and mentally healthy, they are at increased risk for certain health problems as a result of these stresses and the epidemiology of health threats such as HIV and other sexually transmitted infections (STIs). Pediatric clinicians are key in monitoring for such issues, supporting healthy development, and intervening when necessary to prevent or treat the problems for which GLB youth are at increased risk.

Sexual orientation refers to an individual's attraction to others based on sex or gender. It encompasses emotional and erotic desires, physiologic arousal, sexual behavior, sexual identity, and social role. As sexuality develops, youth can be oriented entirely toward a particular sex or gender, or more than one, to various degrees on a continuum. Homosexuality involves orientation toward people of one's same sex or gender, and bisexuality involves orientation toward males and females. Gay is a common term for homosexual males and females; lesbian refers to homosexual females. Some do not fit these categories and use other terms to describe themselves. Those unsure of their orientation are curious or questioning . The term young men who have sex with men ( YMSM ) is sometimes used in the research literature to denote male youth who engage in sexual activity with other males, regardless of how they identify themselves.

Prevalence of Homosexuality and Bisexuality in Youth

Some junior high and high school students self-identify as gay, lesbian, or bisexual. Some who do not identify as GLB report same-sex attraction, fantasies, or behavior. Some are unsure of their sexual orientation. Certainty about sexual orientation tends to increase through adolescence with sexual experience, although one can be aware of one's orientation without having had sexual partners. Those who fear nonacceptance may try to suppress or deny their orientation. Consequently, various aspects of orientation—attraction, behavior, and identity—may not be consistent in an individual and may change during development. Not all youth with homosexual attraction or experience identify as “gay,” consistent in part with reluctance about having or revealing a gay identity and underscoring the differences among attraction, behavior, and identity. A report providing national estimates of the number of high school students with GLB identity in 2015 found that across 25 states and 19 large urban school districts, a median of 2.7% said they were gay/lesbian, 6.4% said they were bisexual, and 4.0% reported being unsure of their sexual orientation.

Development of Sexual Orientation in Childhood and Adolescence

Sexual orientation development appears to begin prenatally and continue through childhood and adolescence and into adulthood. Both gender role behavior in childhood and sexual orientation in puberty and adolescence are partly influenced by prenatal genetic and neuroendocrine factors. Sociocultural and psychological factors also influence sexual development. A gay or lesbian sexual orientation is sometimes preceded developmentally in childhood by nonconforming gender expression , or variation from population averages in expression of gender-related behavior such as activities, interests, styles, and other attributes recognized as masculine or feminine, such as toy preferences and preference for playmates of a particular gender. Although childhood gender nonconformity is not experienced by all gay or lesbian people—and not all children with nonconforming gender role behavior grow up to be gay or lesbian—nonconformity is not uncommon (particularly among males) and leads many gay or lesbian people to feel different from peers in childhood, even before sexual desire or identity emerges. Depending on the setting, gender-nonconforming children may experience ostracism, bullying, or family nonacceptance. These reactions to gender nonconformity can lead to later difficulty with gender-related self-esteem and long-term mental health problems.

Less frequently, gay or lesbian sexual orientation in adolescence is preceded by childhood gender variant identity , a phenomenon in which the gender identity of an individual at any age differs from phenotypic sex and assigned sex at birth (see Chapter 135 ).

Stigma, Risk, and Resilience

Homosexuality has been documented across cultures and historical periods. However, its meaning and acceptance vary greatly with social context. Although gay people are now generally more visible and accepted than previously, youth are often exposed to antihomosexual attitudes. For many GLB youth, revealing their sexual orientation (“coming out”) to family, peers, healthcare providers, and others is a significant step. Specific racial/ethnic, religious, and other demographic groups may experience distinct developmental stressors. For example, black youth report feeling less comfortable than white peers with a gay identity and less comfortable disclosing it.

Some GLB youth experience difficulty coping with stigma . A longitudinal study that investigated bullying and victimization among youth from 5th through 10th grade found that the girls and boys that identified as GLB in 10th grade were more likely than their peers to report that they had been bullied and victimized across grades. GLB youth may be perceived by others as different before they themselves have any GLB attraction or experience, or identify as GLB. Even when not overtly threatened, GLB youth frequently encounter negative attitudes that force them to hide at a time when acceptance holds great developmental significance. Family nonacceptance, feeling unsafe due to school harassment, and peer bullying related to sexual orientation elevate risk in GLB adolescents for depression, anxiety, substance abuse, suicidal thoughts and attempts, and social problems such as truancy, dropping out, running away, and homelessness. Mental health problems, sexual risk taking, or substance use may increase exposure to HIV and other STIs. Stigma may also impede access to healthcare in some communities. Thus, along with factors influencing exposure and susceptibility to health threats, stigma partly mediates elevated risk for health and mental health problems in GLB youth.

Nevertheless, most GLB youth are resilient, with good physical and mental health despite pervasive stress. Family connectedness and school support and safety are important protective factors against depression, suicidal thoughts and attempts, and substance abuse. GLB antiharassment policies and organizations such as genders and sexualities alliances (also sometimes called gay-straight alliances) and antibullying programs are associated with increased school safety for GLB youth. It is therefore important to reduce stigma, support acceptance, and promote resilient coping.

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