Thursday, August 5, 2010

Counseling Gay and Questioning Minors about Coming Out

The following article, published in the August 2010 issue of the American Medical Association's Virtual Mentor, was written by PFLAG regional director Dr. Kay Heggestad and her partner, Dr. Paul Wertsch.

The physician treating a gay or questioning minor whose family is unaware of his or her sexual orientation needs to know how to take a thorough history, conduct a sensitive physical exam, and obtain the needed lab evaluations while maintaining confidentiality. The responsible clinician has good resources on hand to give to the adolescent and can balance communication with parents and his or her primary responsibility to the patient.

History-Taking, Physical Exam, and Opening the Dialogue

When the patient confides in the physician about questioning his or her sexuality, particularly if the family does not know, the physician should acknowledge the courage it took to disclose this personal information and communicate to the patient as soon as possible that being gay is normal and OK, that a person is never too young to recognize his or her sexual orientation, and that the physician will accept the patient regardless of sexual orientation or gender identity. History-taking and discussion about the patient’s sexual orientation must proceed in a nonjudgmental manner and with the assurance that the doctor will not “out” the patient to anyone, including family members [1].

Laboratory Tests and Sexual Health Counseling

Depending on what is found in the history and physical exam, some testing may be indicated, including some or all of the following: serology for hepatitis A, B and C, venereal disease research laboratory test (VDRL), and HIV; throat and cervical cultures for gonococcal (GC) and chlamydial infections; urethral culture for GC, chlamydia, and lympho-granuloma venereum (LGV); and anal culture for GC and human papilloma virus. This is a good time to make sure that the patient is up to date on immunizations, including hepatitis A and B. Although HPV immunization is only recommended for adolescent girls, it should be offered to male patients after they have come out, when the physician can discuss it with their parents [2].

The doctor needs to be frank about the extent of confidentiality. Depending on the clinic, descriptions like “rectal GC culture” may appear on bills. (In some cases, patients can access information about their visits and tests via a clinic Web site—and, if they are minors, so can their parents.) If there are serious symptoms or exam findings (e.g., a high temperature, a syphilitic chancre, a large abscess), the patient’s parents will probably need to be told about those findings so they can give permission for the necessary treatments.

If the testing cannot be kept confidential at the doctor’s office, another source of testing can be identified. Planned Parenthood offers testing for sexually transmitted infections in all 50 states and in Washington, D.C. [3]. They also offer immunizations for sexually transmitted infections (STIs) and safe sex counseling and supplies. There may be other local clinics that perform these tests and immunizations. (Access to and payment for these services, however, may present a problem. Getting into a free clinic can be difficult, but it should be encouraged if the patient must have privacy from his or her parents.)

All teenagers would be well served by an in-depth discussion about safe sex practices, including abstinence.

Coming Out

Consider mental health. As part of the history and exam, it is key that the physician evaluate the adolescent’s mental health as well. Coming out can increase the stress, depression, and anxiety of the already turbulent adolescent years, especially if the adolescent feels ostracized, isolated, or rejected by friends or family. If the teen is agitated and there is a concern about suicide, an emergency admission might be in order. A severe but less acute depression might warrant a visit to a psychiatrist or psychologist. If the doctor refers the adolescent to a mental health professional, it must be understood that the object is not to change the patient’s orientation, but to help him or her with self-acceptance and coping skills and to supply resources outside the home if he or she feels alienated from, abandoned by, or in conflict with loved ones.

The physician should also make patients aware that GLBT people have a somewhat higher rate of depression and substance abuse, probably related to society’s prejudicial attitudes [4]. This knowledge may help motivate the patient to develop appropriate coping skills early on in order to avoid these pitfalls.

Provide resources and support. The physician should have community resources and other information, such as booklets or Web sites, about coming out at hand.

• Parents, Families, and Friends of Lesbians and Gays (PFLAG) has an excellent Web site [5] with informative, free, printable booklets for teens and parents. (For teens considering coming out, we recommend “Be Yourself” [6], and for their parents, “Our Daughters and Sons” [7].) Many cities have PFLAG chapters, which can be contacted through the Web site, and the national office can find local contacts for people who live in places that do not.
• Local GLBT centers may also exist where the patient lives. Some of these have teen groups with adult facilitators for kids who are questioning their sexual orientation or gender identity and considering coming out.
• The Trevor Project operates the only accredited, nationwide, round-the-clock crisis and suicide prevention helpline for LBGTQ youth [8].
• Many high schools and some middle schools have gay-straight alliances [9].
• If the patient has gay relatives or supportive adult relatives and older siblings, he or she should be encouraged to seek support from them.

Bear in mind the patient’s safety. Before any teen comes out to his or her parents, an assessment must be made of whether it is safe to do so. Some parents already suspect their child is gay and welcome the chance to acknowledge the fact. If there is a chance the teen would be thrown out of the home, coming out should probably wait until he or she is financially self-sufficient or has some other reliable long-term source of room and board. And what about discrimination? A 2006 paper published by the National Gay and Lesbian Task Force noted that a disproportionately high number of GLBT kids are homeless, possibly because they were kicked out or just found life intolerable at home after coming out [10]. A physician who knows the patient’s family well may be able to guess how they would take the news.

Protect the patient’s confidentiality when communicating with parents. This brings us to the question of just what the patient’s family should be told. The doctor and patient should plan together what they will say, bring parents or other accompanying people into the exam room, and tell them together. The doctor should explain to the parents that to provide the best care and keep open communication with a teen, he or she must respect the teen’s need for confidentiality. This will allow the patient to feel free to discuss anything. Parents will need to be reassured that medical conditions are being tested for and treated and that the patient’s mental health is being evaluated. If possible, the adolescent should have another appointment in a week or two to follow up about any symptoms or concerns and continue to explore how, and if or when, he or she might come out.

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