How PCPs Can Support Their LGBTQ+ Pediatric Patients

LGBTQ+ Youth and Their Mental Health

26% of high school students in America—1 in 4—identify as part of the LGBTQ+ community. Younger generations, like Gen Alpha and Gen Z, consistently report the highest numbers of LGBTQ+ members compared to older generations. This trend is likely linked to changing societal perceptions, which have normalized the exploration of gender and sexuality.

Despite a nationwide effort to destigmatize this community, stigma, rejection, and discrimination persists, and its presence leads to myriad negative consequences for LGBTQ+ individuals. Young LGBTQ+ members are especially affected, as they face disproportionally high risks of depression, anxiety, suicidal ideation and attempts, healthcare disparities, substance use, bullying, STIs/HIV, and physical/sexual abuse compared to their heterosexual cisgender peers.

It’s important to recognize that these young people are not facing higher risk because of their sexual orientation and gender identity. The risk is there because of the mistreatment and stigmatization they face in their daily lives.

Acceptance and support in the lives of LGBTQ+ youth can go a long way toward mitigating these risks. For example, one study found that suicide attempt rates for transgender youth were only 4% for those who had strongly supportive parents, but rose as high as 60% among those with unsupportive parents. This is incredibly problematic, as 48% of LGBTQ+ youth say that their families make them feel bad about their gender or sexual identity. These researchers also found that if these youth lived in supportive communities, their families tended to increase support over time, leading to improved mental health outcomes for their children.

Impact of LGBTQ+ Stigma in Healthcare Settings

These same issues arise in healthcare settings. 67% of LGB and 61% of transgender youth don’t disclose their sexuality or gender identity to their primary care provider (PCP), often for fear of discrimination or negativity. This is aggravated by most physicians avoiding this topic with their patients, and less than 50% of physicians feeling they have the skills to address sexual orientation and gender identity. Only 18% of pediatricians, many of whom are the PCPs for such youth, report discussing sexual or gender identity with their patients—which means 72% are not. This lack of communication often results in delayed medical care, poor access to treatment, and exacerbates the risks that LGBTQ+ youth already face.

Pediatricians and other PCPs who see patients under 21 can make a difference in these situations. Whether you change the way you approach your office visits or implement changes across your practice, every little bit counts toward creating an inclusive environment. We have compiled a list of evidence-based changes that can be enforced before, during, and after an appointment with any youth. The hope is that these modifications will create a welcoming environment in your office or at your practice for all young patients, especially those who identify as LGBTQ+!

Creating a Positive & Inclusive Experience: Before, During, & After the Appointment

Before the Appointment

The waiting room is your practice’s first impression. Here are some ideas to make this space inclusive for your LGBTQ+ patients!

• Use signage that indicates your practice is LGBTQ+ friendly, like this printable sign from the American Academy of Pediatrics (AAP).
• Provide a basket with personal pronoun pins in the reception area. If your staff are comfortable, include pronoun labels on their nametags or near their workstations.
• If you have space, try and offer single-occupancy bathrooms with all-gender bathroom signage, like this ADA-compliant placard. If you don’t have single-occupancy bathrooms for your patients, you can still place signage that lets them know they can use the bathroom that they feel most comfortable in. The Rainbow Alliance Inclusion Network (RAIN) has some great examples here.
• Add some LGBTQ+ friendly books to the waiting room and office shelves! Even if most of your LGBTQ+ patients are teens, they’ll see these books and recognize the safe space you’re creating. Here are some of our favorite books to add to your practice’s collection:
  • “Bodies Are Cool” by Tyler Feder
  • “A Family is a Family is a Family” by Sara O’Leary and Qin Leng
  • “And Tango Makes Three” by Justin Richardson, Peter Parnell, and Henry Cole
  • “Love Makes a Family” by Sophie Beer
  • “All Kinds of Families” by Suzanne Lang
  • “When Aidan Became a Brother” by Kyle Lukoff and Kaylani Juanita
  • “Julián is a Mermaid” by Jessica Love
• Add inclusive language about gender and sexuality to your office forms. For example, you can provide space for a preferred name, pronouns, sex assigned at birth, and a variety of choices for gender and sexual identity. AAP released example language to incorporate into your existing forms. They note that youth should be allowed to fill out this section of the form confidentially, and it should be stored in a way that abides by your state’s minor confidentiality laws.

During the Appointment

When it’s time for your office visit with a pediatric patient, they are typically accompanied by their parent or guardian. Not all LGBTQ+ youth want to reveal their sexual or gender identity in front of this person, or even you, and others still may not be sure of their identity. Never pressure a youth to share more than they are comfortable with!

Here are some important practices you can implement during office visits:

• Introduce yourself and your pronouns and ask the youth to share theirs. At the very least, don’t assume your patient’s pronouns—try to incorporate gender-neutral language wherever possible. For example, using “they” or “them” to refer to your patient, versus “she” or “he”.
• Explain the bounds of confidentiality to young patients in a clear and developmentally appropriate way. Make sure they understand what you can and can’t keep private.

If you are one of the 77% of physicians who report needing additional training on confidentiality laws, check out this tip sheet from AAP and this list of provider confidentiality requirements in Virginia!

• Build one-on-one time with your patients during their visit with you. This is an especially important practice as they get older and are less comfortable speaking about sensitive topics in front of their parents or guardians.
• Verify that they feel safe and supported at home, school, and in their relationships. You can modify the HEADSSS assessment to explore different areas where your patient may be experiencing risk factors.
• When asking about sexual activity in teens, make sure to clarify whether they are having sex with males, females, or both. Additionally, be sure to reinforce safe sex practices as recommended by AAP and follow the STD/STI testing guidelines from the CDC if a patient is sexually active.

If you want more tips, check out AAP’s best practices for fostering an LGBTQ+ friendly practice. They have a helpful chart of how to incorporate inclusive language into your visits with patients and their families. You can also look at AAP’s office-based care recommendations for LGBTQ+ youth, which is a great resource to keep handy.

After the Appointment

If you think it would be appropriate for your patient, their parents or guardians, or both, you can share additional resources with them after the appointment. We have also linked resources that you can use to continue adapting your practice to be a safe space for LGBTQ+ youth!

Patient Resources

• Gender Identity Workbook for Teens
• Coming Out: A Handbook for LGBTQ+ Young People
• Considerations When Making a Coming Out Plan
• The Gender Unicorn: Understanding Gender & Identity
• LGBTQ National Help Center & Hotline
• The Trevor Project: LGBTQ+ Resources & Hotline

Parent & Caregiver Resources

• Helping Families Understand their LGBTQ+ Children
• How Parents Can Support LGBTQ+ Children
• Caregiver Support Guide for Parents/Caregivers of LGBTQ+ Youth

We’ve also created a handout for parents. Feel free to download this and distribute at your practice when it seems appropriate!

PCP Resources

• A Pediatrician’s Guide to an LGBTQ+ Friendly Practice
• Adolescent Health Care Toolkit
• Gender-Affirming Pediatric Care Toolkit
• Helping Families Support Their LGBTQ+ Children: A Practitioner’s Guide
• National LGBTQIA+ Health Education Center
• Standards of Care for Transgender, Transexual, & Gender Nonconforming People
• Birth Control Across the Gender Spectrums
• A Guide to Caring for LGBTQ+ Youth: for Welfare Providers

We hope this article and the resources linked above have helped you feel more prepared to support your LGBTQ+ pediatric patients. As always, if you need additional support with the mental health of a patient under the age of 21, you can call the VMAP Line for a free consultation and care navigation!