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NAPNAP Position Statement on Health Risks and Needs of Lesbian, Gay, Bisexual, Transgender, and Questioning Youth

      The overall goal in caring for all youth, including those who are lesbian, gay, bisexual, gender nonconforming, transgender, or questioning (LGBTQ), is to promote normal adolescent development, social and emotional well-being, physical health, and reduce any associated physical and mental health risks (
      • Adelson S.L.
      • Stroeh O.M.
      • Ng Y.W.
      Development and mental health of Lesbian, Gay, Bisexual, or Transgender youth in pediatric practice.
      ; American Academy of Pediatrics [
      American Academy of Pediatrics
      Office care of lesbian, gay, bisexual, and questioning youth.
      ,
      American Academy of Pediatrics
      Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.
      ). While many LGBTQ youth navigate adolescence as well as their heterosexual peers, others are exposed to social stigma, discrimination, prejudice, and victimization (both mental and physical;
      • Earnshaw V.A.
      • Reisner S.L.
      • Juvonen J.
      • Hatzenbuehler M.L.
      • Perrotti J.
      • Schuster M.A.
      LGBTQ Bullying: Translating research to action in pediatrics.
      ). In addition, LGBTQ youth may also lack access to supportive, evidence-based, and developmentally appropriate health care (
      • Cicero E.C.
      • Wesp L.M.
      Supporting the health and well-being of transgender students.
      ,
      • Hadland S.E.
      • Yehia B.R.
      • Makadon H.J.
      Caring for lesbian, gay, bisexual, transgender, and questioning youth in inclusive and affirmative environments.
      ,
      • Mustanski B.
      • Birkett M.
      • Greene G.J.
      • Hatzenbuehler M.L.
      • Newcomb M.E.
      Envisioning an America without sexual orientation inequities in adolescent health.
      ). Research has found that LGBTQ children and adolescents experience higher levels of isolation, runaway behavior, homelessness, intimate partner violence, depression, anxiety, suicide, substance use and abuse, pregnancy, physical and emotional abuse, and school or job failure when compared to the rates in heterosexual, cis-gender, and gender conforming youth (
      • Becerra-Culqui T.
      • Liu Y.
      • Nash R.
      • Cromwell L.
      • Flanders D.
      • Getahun D.
      • Goodman M.
      Mental health of transgender and gender noncomforming youth compared with their peers.
      ,
      • DePedro K.T.
      • Gilreath T.D.
      • Jackson C.
      • Esqueda M.C.
      Substance use among transgender students in California public middle and high schools.
      ,
      • Kann L.
      • Olsen E.O.
      • McManus T.
      • Harris W.A.
      • Shanklin S.L.
      • Flint K.H.
      • Zaza S.
      Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9-12—United States and selected sites, 2015.
      ). However, these potentially negative outcomes may be considerably diminished by family support (
      • McConnell E.A.
      • Birkett M.
      • Mustanski B.
      Families matter: Social support and mental health trajectories among lesbian, gay, bisexual, and transgender youth.
      ), the support of other caring adults, and safety at school (
      • Cicero E.C.
      • Wesp L.M.
      Supporting the health and well-being of transgender students.
      ).
      Gender awareness is a normal part of early childhood development. A significant number of young children will express discomfort with their biological sex and/or engage in cross-gender behavior, and parents may bring concerns about these behaviors to pediatric health care providers (
      • Simons L.K.
      • Leibowitz S.F.
      • Hidalgo M.A.
      Understanding gender variance in children and adolescents.
      ). Children questioning their gender identity may have ongoing concerns related to natal gender or even identify as gender fluid or as transgender at any point between childhood and adolescence, requiring education and awareness of local resources by health care providers (
      • Adelson S.L.
      • Stroeh O.M.
      • Ng Y.W.
      Development and mental health of Lesbian, Gay, Bisexual, or Transgender youth in pediatric practice.
      ,
      American Academy of Pediatrics
      Office care of lesbian, gay, bisexual, and questioning youth.
      ,
      American Academy of Pediatrics
      Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.
      ,
      • Hadland S.E.
      • Yehia B.R.
      • Makadon H.J.
      Caring for lesbian, gay, bisexual, transgender, and questioning youth in inclusive and affirmative environments.
      ). Most LGBTQ youth seek some kind of information about sexuality from their health care providers and yet will not disclose sexual orientation or gender identity to a health care provider without being asked in a direct and open manner about sexual attractions and gender identity (
      • Adelson S.L.
      • Stroeh O.M.
      • Ng Y.W.
      Development and mental health of Lesbian, Gay, Bisexual, or Transgender youth in pediatric practice.
      ,
      • Snyder B.K.
      • Burack G.D.
      • Petrova A.
      LGBTQ youth's perceptions of primary care.
      ). Therefore, providers should schedule appropriate time to raise issues of gender identity, sexual orientation, and sexual behavior with all age-appropriate youth patients in a sensitive clinical environment, allowing the youth frequent opportunities to discuss issues, including sexual orientation, as a part of routine care (
      American Academy of Pediatrics
      Office care of lesbian, gay, bisexual, and questioning youth.
      ,
      • Simons L.K.
      • Leibowitz S.F.
      • Hidalgo M.A.
      Understanding gender variance in children and adolescents.
      ). Health care providers should allow for confidential time with the adolescent when discussing issues of gender and sexuality (
      • Hadland S.E.
      • Yehia B.R.
      • Makadon H.J.
      Caring for lesbian, gay, bisexual, transgender, and questioning youth in inclusive and affirmative environments.
      ). In addition, paper and electronic health assessment forms should be revised to include multiple options for selecting sexual attraction preferences, gender identity, and personal selection of pronouns preferred by the youth patient (
      • Cicero E.C.
      • Wesp L.M.
      Supporting the health and well-being of transgender students.
      ,
      • Hadland S.E.
      • Yehia B.R.
      • Makadon H.J.
      Caring for lesbian, gay, bisexual, transgender, and questioning youth in inclusive and affirmative environments.
      ,
      • Steever J.
      • Francis J.
      • Gordon L.P.
      • Lee J.
      Sexual minority youth.
      ).
      In order to advocate for LGBTQ youth, the National Association of Pediatric Nurse Practitioners (NAPNAP) supports the following for pediatric nurse practitioners (PNPs) as well as all other pediatric health care providers.
      • 1.
        NAPNAP opposes all forms of discrimination against individuals based on sexual orientation, gender conformity, and gender identity, while encouraging members to speak out against discrimination and/or victimization of LGBTQ youth.
      • 2.
        Recognize the protective effect of supportive families and engage parents of self-disclosing LGBTQ adolescents in a discussion of the protective effects of family support and the potential negative health effects of punitive and rejecting behaviors. Parents and other family members should be referred to community organizations such as Parents, Families and Friends of Lesbians and Gays (PFLAG), or counseling services with specialization in LGBTQ youth and/or families, so that they may gain a better understanding of the issues their child is facing and find support for themselves (
        • Adelson S.L.
        • Stroeh O.M.
        • Ng Y.W.
        Development and mental health of Lesbian, Gay, Bisexual, or Transgender youth in pediatric practice.
        ,
        • McConnell E.A.
        • Birkett M.
        • Mustanski B.
        Families matter: Social support and mental health trajectories among lesbian, gay, bisexual, and transgender youth.
        ).
      • 3.
        Assure and maintain confidentiality regarding sexual orientation and gender identity in accordance with state and federal regulations pertaining to minors. Given the potential risk for both physical and/or emotional negative consequences for LGBTQ youth from premature disclosure of information, providers should also explore their professional/legal standards regarding confidentiality when the safety of the youth is at risk (
        • Hadland S.E.
        • Yehia B.R.
        • Makadon H.J.
        Caring for lesbian, gay, bisexual, transgender, and questioning youth in inclusive and affirmative environments.
        ).
      • 4.
        Explore each youth's perception of personal gender identity and sexual orientation by using LGBTQ inclusive questions, gender neutral language beginning in early childhood, and allowing them to choose their own pronouns. The health care provider as well as the health care environment should support and promote an LGBTQ-safe space for all youth and an atmosphere of acceptance to facilitate health care interactions (
        • Mustanski B.
        • Birkett M.
        • Greene G.J.
        • Hatzenbuehler M.L.
        • Newcomb M.E.
        Envisioning an America without sexual orientation inequities in adolescent health.
        ,
        • Perron T.
        • Kartoz C.
        • Himelfarb C.
        LGBTQ Youth Part 1.
        ,
        • Simons L.K.
        • Leibowitz S.F.
        • Hidalgo M.A.
        Understanding gender variance in children and adolescents.
        ).
      • 5.
        NAPNAP encourages members to recognize the distinction between biological sex and gender and to adhere to current clinical guidelines of youth with gender dysphoria or who identify as transgender (
        • Simons L.K.
        • Leibowitz S.F.
        • Hidalgo M.A.
        Understanding gender variance in children and adolescents.
        ). Pediatric providers should offer patients and their family's referrals for counseling and appropriate support services, which may include hormone therapy or referral to a specialist when appropriate.
      • 6.
        NAPNAP opposes the use of reparative therapy for youth and advises against the use of such practices which are not only ineffective but also considered harmful (
        • Mustanski B.
        Future directions in research on sexual minority adolescent mental, behavioral, and sexual health.
        ).
      • 7.
        Pediatric health care is best delivered to youths in an in an individualized manner with a focus on health promotion and risk-reduction. Health care should be tailored to particular issues faced by the individual LGBTQ youth; especially when youthd are questioning or struggling with sexual orientation or gender identity (
        American Academy of Pediatrics
        Office care of lesbian, gay, bisexual, and questioning youth.
        ,
        • Hadland S.E.
        • Yehia B.R.
        • Makadon H.J.
        Caring for lesbian, gay, bisexual, transgender, and questioning youth in inclusive and affirmative environments.
        ).
      • 8.
        NAPNAP supports pediatric-focused advanced practice registered nurse (APRN) participation in community and/or school education efforts to promote tolerance and understanding of LGBTQ issues. Support and education of the community is key for changing environments and decreasing bullying, harassment, and violence aimed at LGBTQ youth (
        • Perron T.
        • Kartoz C.
        • Himelfarb C.
        LGBTQ Youth Part 1.
        ,
        • Perron T.
        • Kartoz C.
        • Himelfarb C.
        LGBTQ Part 2.
        ). NAPNAP, a health professional organization whose mission is to empower PNPs, pediatric-focused APRNs, and their interprofessional partners to enhance child and family health through leadership, advocacy, professional practice, education, and research, believes that in order to fully address the needs of all youth, pediatric health care providers should be supportive of LGBTQ youth and provide an open and safe health care environment. NAPNAP also supports exploring each youth's perception of his or her gender and sexual orientation through the use of inclusive questions and gender neutral language beginning in early childhood. Pediatric-focused APRNs should work with youth and their families to promote open communication, understanding, and acceptance of their child/adolescent, regardless of sexual orientation and gender identity and should advocate for local, state, and national policies that promote safe environments for all developing children.
      Note. For the purpose of this position statement the term youth is used to refer to a child or adolescent in regards to age-appropriate disclosure or discussion about sexual orientation or gender identity with a provider. As pediatric health care providers, we must be aware that there is no set age for self disclosure and self identification, and it will vary with each child/adolescent. The term youth was elected for use in this position statement.

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