Homosexuality and Adolescence (RE9332)
|Pediatrics|| Volume 92, Number 4|| October, 1993, p 631-634|
Homosexuality and Adolescence (RE9332)
Committee on Adolescence
AMERICAN ACADEMY OF PEDIATRICS
The American Academy of Pediatrics issued its first statement on
homosexuality and adolescence in 1983. The past decade has witnessed increased
awareness of homosexuality, changing attitudes toward this sexual orientation,
and the growing impact of the human immunodeficiency virus (HIV). Therefore, an
updated statement on homosexuality and adolescence is timely.
Homosexuality is the persistent sexual and emotional attraction to members
of one's own gender and is part of the continuum of sexual expression. Many gay
and lesbian youths first become aware of and experience their sexuality during
adolescence. Therefore, pediatricians who care for teenagers need to
understand the unique medical and psychosocial issues facing homosexually
oriented youths (see
for a definition of terms).
ETIOLOGY AND PREVALENCE
Homosexuality has existed in most societies for as long as recorded
descriptions of sexual beliefs and practices have been available. Societal
attitudes toward homosexuality have had a decisive impact on the extent to
which individuals have hidden or made known their sexual orientation.
In 1973, the American Psychiatric Association reclassified homosexuality as
a sexual orientation/expression rather than as a mental disorder.  The
etiology of homosexuality remains unclear, but the current literature and the
vast majority of scholars in this field state that one's sexual orientation is
not a choice, that is, individuals no more choose to be homosexual than
heterosexual. [2,3] However, the expression of sexual behaviors and lifestyle
is a choice for all teenagers regardless of sexual orientation.
During the adolescent years, many youths engage in sexual experimentation.
Sexual behavior during this period does not predict future sexual orientation.
Gay, lesbian, and heterosexual youths may engage in sexual activities with
members of the same or opposite sex. Kinsey et al, [4,5] from their studies in
the 1930s and 1940s, reported that 37% of men had at least one homosexual
experience resulting in orgasm. From the same cohort, Kinsey reported that 4%
of women and 10% of men were exclusively homosexual for at least 3 years of
their lives. Sorenson  surveyed a group of 16- to 19-year-olds and reported
that 6% of females and 17% of males had at least one homosexual experience.
While the Kinsey data suggest that 4% of adult men and 2% of adult women are
exclusively homosexual in their behavior and fantasies, the current prevalence
of homosexual behavior and identity among adolescents remains to be defined.
Gay and lesbian adolescents share many of the developmental tasks of their
heterosexual peers. These include establishing a sexual identity and deciding
on sexual behaviors, whether choosing to engage in sexual intercourse or to
abstain. Due to the seriousness of sexually transmitted diseases (STDs),
abstinence should be promoted as the safest choice for all adolescents.
However, not all youths will choose abstinence. The current reality is that a
large number of adolescents are sexually active. Therefore, all adolescents
should receive sexuality education and have access to health care resources.
It is important to provide appropriate anticipatory guidance to all youths
regardless of their sexual orientation. Physicians must also be aware of the
important medical and psychosocial needs of gay and lesbian youths. 
The epidemic of the HIV infection highlights the urgency of making
preventive services and medical care available to all adolescents regardless of
sexual orientation or activity. Heterosexual and homosexual transmission of
HIV infection is well established. The role of injectable drugs of abuse in
HIV transmission is also well known. [3,8] Sex between males accounts for
about half of the non-transfusion-associated cases of acquired immunodeficiency
syndrome (AIDS) among males between the ages of 13 and 19 years.  While not
all gay adolescents engage in high-risk sex (or even have sex), their
vulnerability to HIV infection is well recognized. The pediatrician should
encourage adolescents to practice abstinence. However, many will not heed this
important message. Thus, practical, specific advice about condom use and other
forms of safer sex should be included in all sexuality education and prevention
Issue of Trust
Quality care can be facilitated if the pediatrician recognizes the specific
challenges and rewards of providing services for gay and lesbian adolescents.
This care begins with the establishment of trust, respect, and confidentiality
between the pediatrician and the adolescent. Many gay and lesbian youths avoid
health care or discussion of their sexual orientation out of fear that their
sexual orientation will be disclosed to others. The goal of the provider is
not to identify all gay and lesbian youths, but to create comfortable
environments in which they may seek help and support for appropriate medical
care while reserving the right to disclose their sexual identity when ready.
Pediatricians who are not comfortable in this regard should be responsible for
seeing that such help is made available to the adolescent from another
SPECIAL ASPECTS OF CARE
A sexual history that does not presume exclusive heterosexuality should be
obtained from all adolescents. [3,9] Confidentiality must be emphasized except
in cases in which sexual abuse has occurred. It is vital to identify high-risk
behavior (anal or vaginal coitus, oral sex, casual and/or multiple sex
partners, substance abuse, and others).
A thorough and sensitive history provides the groundwork for an accurate
physical examination for youths who are sexually experienced.  Depending
on the patient's sexual practices, a careful examination includes assessment of
pubertal staging, skin lesions (including cutaneous manifestations of STDs,
bruising, and other signs of trauma), lymphadenopathy (including inguinal), and
anal pathology (including discharge, venereal warts, herpetic lesions,
fissures, and others). Males need evaluation of the penis (ulcers, discharge,
skin lesions), scrotum, and prostate (size, tenderness). Females need
assessment of their breasts, external genitalia, vagina, cervix, uterus, and
All males engaging in sexual intercourse with other males should be
routinely screened for STDs, including gonorrhea, syphilis, chlamydia, and
enteric pathogens. The oropharynx, rectum, and urethra should be examined and
appropriate cultures obtained when indicated. [3,9]
Immunity to hepatitis B virus should be assessed. Immunization is
recommended for all sexually active adolescents and should be provided for all
males who are having or anticipate having sex with other males.  HIV
testing with appropriate consent should be offered; this includes counseling
before and after voluntary testing.
Women who have sex exclusively with other women have a low incidence of
STDs, but can transmit STDs and potentially HIV if one partner is infected.
Since lesbian women who engage in unprotected sex with men face risks of both
sexually acquired infections and pregnancy, the pediatrician should offer them
realistic birth control information and counseling on STD prevention.
The psychosocial problems of gay and lesbian adolescents are primarily the
result of societal stigma, hostility, hatred, and isolation.  The gravity
of these stresses is underscored by current data that document that gay youths
account for up to 30% of all completed adolescent suicides.  Approximately
30% of a surveyed group of gay and bisexual males have attempted suicide at
least once.  Adolescents struggling with issues of sexual preference
should be reassured that they will gradually form their own identity  and
that there is no need for premature labeling of one's sexual orientation. 
A theoretical model of stages for homosexual identity development composed by
Troiden  is summarized in
The health care professional should explore each adolescent's perception of
homosexuality, and any youth struggling with sexual orientation issues should
be offered appropriate referrals to providers and programs that can affirm the
adolescent's intrinsic worth regardless of sexual identity. Providers who are
unable to be objective because of religious or other personal convictions
should refer patients to those who can.
Gay or lesbian youths often encounter considerable difficulties with their
families, schools, and communities. [16,18,19] These youths are severely
hindered by societal stigmatization and prejudice, limited knowledge of human
sexuality, a need for secrecy, a lack of opportunities for open socialization,
and limited communication with healthy role models. Subjected to overt
rejection and harassment at the hands of family members, peers, school
officials, and others in the community, they may seek, but not find,
understanding and acceptance by parents and others. Parents may react with
anger, shock, and/or guilt when learning that their child is gay or lesbian.
Peers may engage in cruel name-calling, ostracize, or even physically abuse
the identified individual. School and other community figures may resort to
ridicule or open taunting, or they may fail to provide support. Such rejection
may lead to isolation, runaway behavior, homelessness, domestic violence,
depression, suicide, substance abuse, and school or job failure. Heterosexual
and/or homosexual promiscuity may occur, including involvement in prostitution
(often in runaway youths) as a means to survive. Pediatricians should be aware
of these risks and provide or refer such youths for appropriate counseling.
The gay or lesbian adolescent should be allowed to decide when and to whom
to disclose his/her sexual identity. In particular, the issue of informing
parents should be carefully explored so that the adolescent is not exposed to
violence, harassment, or abandonment. Parents and other family members may
derive considerable benefit and gain understanding from organizations such as
Parents and Friends of Lesbians and Gays (PFLAG). [3,18]
Concept of Therapy
Confusion about sexual orientation is not unusual during adolescence.
Counseling may be helpful for young people who are uncertain about their sexual
orientation or for those who are uncertain about how to express their sexuality
and might profit from an attempt at clarification through a counseling or
psychotherapeutic initiative. Therapy directed specifically at changing sexual
orientation is contraindicated, since it can provoke guilt and anxiety while
having little or no potential for achieving changes in orientation. While
there is no current literature clarifying whether sexual abuse can induce
confusion in one's sexual orientation, those with a history of sexual abuse
should always receive counseling with appropriate mental health specialists.
Therapy may also be helpful in addressing personal, family, and environmental
difficulties that are often concomitants of the emerging expression of
homosexuality. Family therapy may also be useful and should always be made
available to the entire family when major family difficulties are identified by
the pediatrician as parents and siblings cope with the potential added strain
SUMMARY OF PHYSICIAN
Pediatricians should be aware that some of the youths in their care may be
homosexual or have concerns about sexual orientation. Caregivers should
provide factual, current, nonjudgmental information in a confidential manner.
These youths may present to physicians seeking information about homosexuality,
STDs, substance abuse, or various psychosocial difficulties. The pediatrician
should ensure that each youth receives a thorough medical history and physical
examination (including appropriate laboratory tests), as well as STD (including
HIV) counseling and, if necessary, appropriate treatment. The health care
professional should also be attentive to various potential psychosocial
difficulties and offer counseling or refer for counseling when necessary.
The American Academy of Pediatrics reaffirms the physician's responsibility
to provide comprehensive health care and guidance for all adolescents,
including gay and lesbian adolescents and those young people struggling with
issues of sexual orientation. The deadly consequences of AIDS and adolescent
suicide underscore the critical need to address and seek to prevent the major
physical and mental health problems that confront gay and lesbian youths in
their transition to a healthy adulthood.
COMMITTEE ON ADOLESCENCE, 1992 TO 1993
Roberta K. Beach, MD, Chair
Suzanne Boulter, MD
Marianne E. Felice, MD
Edward M. Gotlieb, MD
Donald E. Greydanus, MD
James C. Hoyle Jr, MD
I. Ronald Shenker, MD
Richard E. Smith, MD, American College of Obstetricians and Gynecologists
Michael Maloney, MD, American Academy of Child and Adolescent Psychiatry
Diane Sacks, MD, Canadian Paediatric Society
Samuel Leavitt, MD, Section on School Health
Donna Futterman, MD, Albert Einstein College of Medicine
John D. Rowlett, MD, Children's Hospital of Savannah, GA
S. Kenneth Schonberg, MD, Albert Einstein College of Medicine
1. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 3rd ed, revised. Washington, DC: American Psychiatric
2. Savin-Williams RC. Theoretical perspectives accounting for adolescent
homosexuality. J Adolesc Health Care. 1988;9:2
3. Rowlett J, Patel DR, Greydanus DE. Homosexuality. In: Greydanus DE,
Wolraich M, eds. Behavioral Pediatrics. New York, NY:
4. Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior in the Human Male.
Philadelphia, PA: WB Saunders; 1948
5. Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior in the Human Female.
Philadelphia, PA: WB Saunders; 1953
6. Sorenson RC. Adolescent Sexuality in Contemporary America. New
York, NY: World Publishing; 1973
7. Remafedi GJ. Adolescent homosexuality: psychosocial and medical
implications. Pediatrics. 1987;79:331-337
8. Centers for Disease Control. AIDS Surveillance Update. Atlanta, GA;
9. Remafedi GJ. Sexually transmitted diseases in homosexual youth. Adolesc
Med State Art Rev. 1990;1:565-581
10. Brookman RR. Reproductive health assessment of the adolescent. In:
Hofmann AD, Greydanus DE, eds. Adolescent Medicine. 2nd ed. Norwalk,
CT: Appleton-Lange; 1989:347-351
11. Centers for Disease Control. Hepatitis B virus: a comprehensive strategy
for eliminating transmission in the United States through universal childhood
vaccination: recommendations of the Immunization Practices Advisory Committee.
MMWR. 1991;40(No. RR-13):13-16
12. Martin AD. Learning to hide: the socialization of the gay adolescent. In:
Feinstein SC, Looney JG, Schwarzenberg AZ, Sorosky AD, eds. Adolescent
Psychiatry. Chicago, IL: University of Chicago Press; 1982:52-65
13. US Dept of Health and Human Services. Report of the Secretary's Task
Force on Youth Suicide. Washington, DC: US Dept of Health and Human
14. Remafedi G, Farrow JA, Deisher RW. Risk factors for attempted suicide in
gay and bisexual youth. Pediatrics. 1991;87:869-875
15. Remafedi G, Resnick M, Blum R, et al. Demography of sexual orientation in
adolescents. Pediatrics. 1992;89:714-721
16. Greydanus DE, Dewdney D. Homosexuality in adolescence. Semin Adolesc
17. Troiden RR. Homosexual identity development. J Adolesc Health
18. Peterson PK, ed. Special symposium: gay and lesbian youth. In:
American Academy of Pediatrics, Adolescent Health Section Newsletter.
19. Herek GM, Kimmel DC, Amaro H, et al. Avoiding heterosexist bias in
psychological research. Am Psychol. 1991;46:957-963
This statement has been approved by the Council on Child and Adolescent
The recommendations in this statement do not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking into
account individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright (c) 1993 by the American Academy of
No part of this statement may be reproduced in any form or by any means
without prior written permission from the American Academy of Pediatrics except
for one copy for personal use.
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