Questions to ask young male patients about Sexual Orientation or Gender Identity

Overview

There is an important distinction between sexual orientation and gender identity that can be overlooked in clinical practice.  Developmentally, gender identity emerges at a younger age than does sexual orientation, and often has little implication for sexual orientation. (Rafferty)

Most adolescents and adults identify themselves as heterosexual. However, health care providers must be aware that young males may be members of a sexual minority. Male sexual minorities are young men whose sexual orientation may be gay, bisexual, queer, questioning or asexual.  They may also be young men whose gender identity does not match their anatomy.  These young men may have gender dysphoria¹ and are often referred to as transgendered. Those who are transgendered can be heterosexual, homosexual or bisexual.

Health care providers should be aware of the significant psychological, social and medical issues that male sexual minorities face.  Almost all of these issues arise from the stigmatization that these youth face, rather than from the orientation itself.²

Sexual Orientation

Sexual orientation is not a diagnostic condition.  The provider should not make assumptions about a teen’s sexual orientation.  Rather, the practitioner must create an environment in which the adolescent can discuss any questions or worries that they have, whether they identify themselves as heterosexual, homosexual, have found that they are attracted to people of the same gender, have had a sexual encounter with someone of the same gender or are confused about their feelings.³ Sexual orientation can comprise of three independent areas; sexual attraction, sexual practice, and sexual identity.

Gender Identity

Young males whose gender identity does not match their anatomy are often referred to as transgendered, or gender dysmorphic, a diagnostic condition defined by the DSM-5.⁴  Those who are transgendered can be heterosexual, homosexual or bisexual. The medical and psychological needs of transgendered youth are many.

Gender dysmorphia is distinct from transvestism. Young people who are transvestites are sometimes, but not always, homosexual. Transvestites get pleasure from dressing in the clothing of the opposite sex. They can be heterosexual, homosexual or bisexual.⁵

Because both sexual orientation and gender identity might be “fluid” or subject to change during adolescence, providers should approach gender identity, identity and practices independently (Rafferty), and should be aware of terms that young men use to describe sexuality.⁶

Compared with their heterosexual youth, sexual minority males report higher rates of verbal, physical, and sexual harassment and violence.  Most sexual minority and gender nonconforming males have heard homophobic comments at school and/or felt unsafe at school; many report being threatened with a weapon or attacked at school.^7,8 Together these findings support screening adolescent males, particularly gender nonconforming and sexual minority males, for home, school, community and intimate partner violence. ⁹

Compared with men who have sex with women, rates of HIV and STIs are higher among young men who have sex with men (MSM).^10,11 MSM may or may not identify as gay, underscoring the need to separate sexual behavior from sexual identity (Rafferty). Young MSM of color have the highes rates of HIV and STIs.¹² MSM account for the largest numbers of new HIV infections. In 2009 young MSM accounted for 69% of new HIV infections and 44% among all MSM. From 2006 to 2009, HIV infections among young black/African American gay and bisexual men increased 48%.¹³ HIV prevalence among young MSM is estimated at 7.2% (5.6% for those 15–19 years of age, 8.6% for those 20 –22 years of age).¹⁴ In 2006, 64% of the reported primary and secondary syphilis cases were among MSM.¹⁵ Gay and bisexual identified young men report higher levels of risk behaviors, including delinquency, aggression, and substance use.^{(as cited in 16)}

As discussed in the American Academy of Pediatrics (AAP) statement on sexual orientation and adolescents¹⁷ boys who are questioning and gay and do not have supportive environments are at increased risk of social isolation, school failure, family conflict, substance abuse, depression, suicide, and stigmatization.^{18,19 (cited in 20)}

Sexual minority youth at are high risk for suicide.  Providing respectful, understanding, and confidential care to these youth can be a matter of life and death (which we may not realize until it is too late).  Bullying of sexual minorities is also an important issue for providers.  Finally, and unfortunately, sexual minority you face higher rates of abuse, neglect, and homelessness (including “throw-aways” or homeless kids whose parents refuse to allow back home).  (Rafferty)