Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care

INTRODUCTION — The term "sexual minoritized" encompasses a variety of gender and sexual identities and expressions that differ from cultural norms (eg, lesbian, gay, bisexual, transgender), as well as identities and expressions that defy discrete labels [1].

This topic will focus on the primary care of sexual minoritized youth who identify themselves as lesbian, gay, bisexual, or unsure (questioning) of their sexual identity, who avoid discrete sexual orientation labels, and who have had sexual contact with persons of the same sex or persons of both sexes. The epidemiology and health concerns of sexual minoritized youth are discussed separately. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns".)

Health care for children and adolescents with gender diversity and adult sexual minorities is discussed separately. (See "Management of transgender and gender-diverse children and adolescents" and "Sexual and gender minority women (lesbian, gay, bisexual, transgender, plus): Medical and reproductive care" and "Primary care of gay men and men who have sex with men".)

OVERVIEW — The components of preventive health and health maintenance for sexual minoritized youth are the same as for all adolescents (eg, surveillance and screening of health and development, immunizations, anticipatory guidance, and counseling with targeted health promotion and risk reduction) [2-6]. (See "Guidelines for adolescent preventive services".)

Additional concerns for sexual minoritized youth include the disclosure process and the potential for stigmatization and discrimination at home, school, and in society. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Stigmatization and minority stress' and "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Disclosure'.)

In surveys, aspects of care that are particularly important to sexual minoritized youth include privacy and confidentiality, being treated with respect, skillful and nonjudgmental communication, and competence of the health care provider [7,8].

General principles — Competent care of sexual minoritized youth requires understanding of the development of adolescent sexuality, ability to identify mental health issues related to disclosure or victimization, and familiarity with the physical and sexual health issues related to sexual orientation [4]. However, health care providers may lack training in health issues of sexual minoritized patients [9]. Clinicians who are neither comfortable with their ability nor willing to become sufficiently knowledgeable to provide high-quality care to sexual minoritized youth and youth with diverse sexual behaviors should refer them to more appropriate colleagues [3,10,11].

Similarly, clinicians with negative views of sexual minorities based on their cultural, religious, or personal bias should refer sexual minoritized youth to more appropriate colleagues. Sexual minorities routinely report discrimination, bias, and lack of trained providers when attempting to use the health care system, leading some to avoid health care altogether. In a 2005 survey, 22 percent of lesbians reported prior bad experience(s) with health care, 18 percent reported feeling afraid or embarrassed to talk about health issues, and 15 percent had specific concerns regarding discrimination [12].

General principles outlined by the American Academy of Pediatrics [3,6,13-15], Society for Adolescent Health and Medicine [4], and American Academy of Child and Adolescent Psychiatry for the care of sexual minoritized youth include [16]:

●Provide time and space for confidential conversations

●Assess and build upon the youth's strengths

●Approach sensitive topics respectfully; instead of lecturing, engage the youth in conversation

●Aim to foster healthy psychosexual development, integrated identity formation, and adaptive functioning

●Avoid assumptions (adolescents may not view themselves as lesbian, gay, or bisexual even though they are having sex with same-sex partners)

●Make the office welcoming to sexual minoritized youth (whether or not they have disclosed their orientation); this may encompass:

•Staff who ensure privacy and confidentiality

•Staff who ask patients for their preferred name and gender on intake

•Forms and questions that do not assume heterosexuality and permit nonbinary responses to questions about gender and orientation

•Provision of information and resources for sexual minoritized youth

•A policy of openness, respect, and value of the individual patient's experience

•Waiting and examination room environments containing health promotion materials and resource information for sexual minoritized youth

Privacy and confidentiality — Privacy and confidentiality are crucial when discussing potentially sensitive information with adolescents [14,17,18]. Understanding legal requirements, institutional policies, and local laws can help providers educate adolescents about the difference between privacy and confidentiality and make responsible plans to protect sensitive health information [19]. Privacy refers to an individual's ability to control the timing, amount, and circumstances under which information about oneself is disclosed [20]. Confidentiality pertains to the treatment of information once it has been disclosed. (See "Confidentiality in adolescent health care" and "Consent in adolescent health care".)

To illustrate with an example, a youth may have an explicit conversation with their medical provider about their sexual orientation and behaviors that can be kept private (ie, between the provider and the patient). However, information recorded in the medical record is available upon request by parent(s). Although most states provide adolescents with some measure of consent and confidentiality for testing and treatment of sexually transmitted infections, many states do not protect other reproductive health information (including sexual orientation and activity, pregnancy testing, contraception). Explicit assurance of privacy and confidentiality (and exceptions to privacy and confidentiality) regarding discussions and details of emerging sexuality helps adolescents understand what to expect and what types of sensitive information they may safely disclose to their health care provider [3]. Documentation of confidential information in the medical record is discussed separately. (See "Confidentiality in adolescent health care", section on 'Medical records'.)

PSYCHOSOCIAL HISTORY — A comprehensive psychosocial history allows the clinician to assess the adolescent's strengths and potential health risks [6,13]. Components of the adolescent psychosocial history that permit targeted anticipatory guidance and counseling for risk reduction often are compiled into acronyms that move from less sensitive to more sensitive topics, such as SHEADDSSS: Strengths, Home, Education and employment, Activities, Drugs and tobacco, Depression and Suicidality, Safety, and Sexuality [21,22].

Strengths — Beginning with questions that identify the adolescent's strengths and assets (eg, supportive friends, academic achievement) may contribute to a nurturing provider-patient relationship, helping to build the adolescent's self-esteem, which may influence behavior and decrease risk [5,23-27]. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Potential protective factors'.)

Home — It is important to understand the adolescent's perception of how things are at home because the relationship of sexual minoritized youth to their parent(s)/caretaker(s) and families is central to their health and well-being. Parental/caretaker(s) caring, support, and positive response to their child's sexual orientation appear to be associated with better health outcomes for sexual minoritized youth [28]. Parental/caretaker rejection is associated with increased risk of adverse outcomes including depression, suicide attempts, substance use, victimization, high-risk sexual behaviors, sexually transmitted infections (STIs), and homelessness [29-31].

It is important to ask, and not make assumptions, about parents' and family members' support and acceptance of the individual youth and their views on sexual minorities. Asking directly about perceived and explicit support or rejection allows a provider to understand the family milieu and resources. Asking about methods of conflict resolution and communication within the home may help the provider to understand the potential for violence if the youth discloses an alternative sexual orientation or gender identity.

Education and employment — When asking about education and employment in the psychosocial history of sexual minoritized youth, it is particularly important to ask about victimization and absenteeism related to victimization. For example, "What is the general attitude towards lesbian, gay, bisexual, or transgender issues at your school?"; "Are you being teased, bullied, or harassed at school?" [11].

Many sexual minoritized youth experience discrimination and victimization at school [32-35]. School victimization due to perceived sexual minoritized status has been associated with social isolation, low self-esteem, depression, and suicidality [36-38]. Identification of a negative school environment and knowing what resources are available at school are necessary to intervene. (See 'Safety' below and "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'School'.)

In a 2011 national survey of 8584 lesbian, gay, bisexual, and transgender students (13 to 20 years), 60 percent of students who were harassed or assaulted in school did not report the incident to school staff, believing little to no action would be taken or the situation could become worse if reported; 37 percent of students who did report an incident said that no action was taken in response [32]. Fewer resources related to sexual minoritization were available to middle school than high schools students and students who attended public or religious school (versus private/nonreligious schools), and schools located in the Southern and United States, small towns, or rural areas.

For many sexual minoritized youth, experience of discrimination and bias in school can lead to anticipation of discrimination in the workplace and may limit perceived career opportunities [39,40]. Sexual minoritized status may be less important than prior experience of bias. In a survey of 119 sexual minoritized adults, those who experienced high levels of discrimination reported that sexual orientation negatively affected their career opportunities satisfaction [39]. Lack of perceived employment opportunities may lead sexual minoritized youth to resort to providing sex in exchange for money, housing, or drugs, increasing their risk of victimization and STIs. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Health risks'.)

A variety of human rights and reproductive justice organizations provide information about protected legal rights for safe schools and workplaces (eg, American Civil Liberties Union, Lambda Legal).

Activities — Asking sexual minoritized youth about their activities helps to assess their social connectedness, which has important implications for health outcomes [41]. Sexual minoritized youth are at increased risk of social isolation. Isolation may be cognitive (lack of information about sexual minoritized couples and relationships), social (lack of positive role models and opportunities to network with sexual minoritized peers), or emotional (lack of acceptance, support, and resources) [42].

It is important to ask all adolescents, including sexual minoritized youth, about use of electronic media [43], and specifically if they use electronic media for sexual purposes (eg, viewing pornography, meeting partners, online dating) [6,44,45].

Use of electronic media may be associated with benefits and risks [44,46,47]. Benefits include:

●Increased educational and social networking opportunities, possibly compensating for limited personal relationships and offline resources (especially for sexual minoritized youth without transportation, in rural areas, or who are not yet out to their family or local community) [48]

●Exposure to a broader array of ideas, backgrounds, and persons than is available in their immediate family or local community [44]

●Increased access to information about health (eg, STIs), sensitive or private concerns, confidentiality, or sexuality [49,50]; however, the information may be inaccurate or inappropriate [44,46]

Risks of electronic media use may include:

●Increased risk of victimization; sexual minoritized youth are at risk for victimization by individuals they meet online [51]; in one series of 129 cases of internet-initiated sex crimes against minors, 25 percent of cases involved adolescent male victims and adult male perpetrators, suggesting that gay, bisexual, or questioning males may be vulnerable to sexual victimization (the victim and perpetrator often met in gay-oriented chat rooms) [52,53]

●Threats to privacy or confidentiality

●Increased risk of cyber bullying, which can have significant and life-threatening consequences for all youth [44,46,47,54,55]; in a 2011 national survey of 8584 lesbian, gay, bisexual, and transgender students (13 to 20 years), 55 percent reported having been harassed or threatened by their peers via electronic media during the past year [32]

Drugs, alcohol, and tobacco — In population-based surveys, sexual minoritized youth are consistently at greater risk for tobacco and substance abuse than their nonsexual minoritized peers [56-59]. Male sexual minoritized youth also are at increased risk to misuse anabolic-androgenic steroids [60]. Tobacco and/or substance use may be a marker for other high-risk health behaviors (eg, exchange sex, sex with drug users, multiple partners, unprotected sex) [61,62]. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Tobacco and substance use'.)

The American Academy of Pediatrics (AAP) and the AAP/Bright Futures guidelines suggest screening for alcohol, tobacco, and substance use annually, beginning as early as age 9 years for alcohol and age 11 years for other substances [5]. The guidelines suggest asking the adolescent directly about experimentation with or use of tobacco (including smokeless tobacco), electronic cigarettes, alcohol, or drugs (including inhalants, anabolic steroids, and nonmedical use of prescription stimulants). If substance use is reported, additional information is gathered regarding duration, amount, and frequency. The CRAFFT questionnaire (a brief screening tool for identification of problematic substance use) and a two-question screen for alcohol use are discussed separately [63,64]. (See "Screening tests in children and adolescents", section on 'Nicotine, alcohol, and substance use'.)

Depression and suicidality — It is important to inquire about emotional health and suicidality. In addition to the usual challenges of adolescence, sexual minoritized youth commonly experience sexual discrimination and bias. They may be socially isolated, have low self-esteem, and have a variety of internalizing (eg, anxiety, depression) and/or externalizing (eg, aggression) symptoms [65-67].

Identification of depression and suicidality in adolescents are discussed separately. (See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Assessment' and "Suicidal ideation and behavior in children and adolescents: Evaluation and management", section on 'Prevention'.)

Sexual minoritized youth report higher rates of suicidality (ideation and attempt) than heterosexual youth [68-70]. In observational studies of sexual minoritized youth, suicidality is associated with previous suicide attempt(s), victimization, lack of support in the family and community, impulsivity, earlier age of same-sex attraction, depressive symptoms, hopelessness, symptoms of conduct disorder, and impulsivity [71-77].

Asking specifically about self-harm, including cutting, burning, or other harmful behaviors, may provide additional information about a youth's mental health and coping mechanisms. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Mental health and self-harm' and "Nonsuicidal self-injury in children and adolescents: Assessment".)

In addition to asking sexual minoritized youth about suicidality and self-harm, it is important to consider the possibility of unrecognized or undisclosed gender or sexual concerns in youth who present with suicidality or other mental health concerns. These youth may present in the mental health setting for mood and behavior concerns before they disclose, and thus avail themselves to support for their sexual minoritized status. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Early identification of gender or sexual diversity' and 'Indications for referral' below.)

Safety — It is important to ask sexual minoritized youth if they feel safe at home, school, and in the community and to offer appropriate support and intervention as indicated [78].

●Do you feel safe at school or work? Is anyone teasing, bullying, or verbally harassing you in the school/work setting? Has anyone pushed, hit, or physically threatened you at school or work? Has anyone been sexually inappropriate or coercive at school or work? If you are in a situation where you feel threatened, can you go to teachers, counselors, or a supervisor to ask for help? Have you ever asked for assistance with a threatening situation at school or work?

●Do you feel safe in your neighborhood? Have you ever been verbally, physically, or sexually harassed by other youth or adults in your neighborhood?

●Do you feel safe at home? Have you ever been verbally, emotionally, physically, or sexually abused by a parent, relative, or caregiver? Have you ever been in department of family and youth services custody for difficulties at home? Do you feel like you can openly discuss safety concerns or other issues with your parents at home?

Sexual minoritized youth are more likely than their heterosexual peers to report feeling unsafe in a variety of settings, reporting higher rates of bullying, dating violence, physical and sexual abuse, and hate crimes than heterosexual peers [35,79-81]. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Victimization and violence'.)

Sexuality — Accurate information about specific sexual behaviors is necessary to appropriately target risk reduction counseling. Youth who are sexually active and engaging in same-sex activities may benefit from targeted risk reduction counseling, screening, or services that differ from those typically recommended for adolescents (eg, hepatitis C screening, pre-exposure antiretroviral prophylaxis for HIV, etc). Primary care providers do not necessarily need to provide these services themselves but may be the first to recognize that an adolescent may benefit from additional care. (See 'Anticipatory guidance/counseling' below and 'Screening and surveillance' below.)

Opportunities for screening and counseling for risk reduction may be missed if sexual orientation (particularly sexual behaviors) is not discussed/disclosed. Adolescents may not disclose this information unless they are specifically asked [82]. They also may not offer this information if they sense that it will make their provider uncomfortable or that their provider will have a negative reaction.

The sexual history can be introduced by saying, "To understand your risk for STIs, I need to understand the kind of sex you have had in the past as well as recently."

General principles in obtaining a sexual history for all adolescents that are particularly relevant to sexual minoritized youth include "just asking," avoiding assumptions, normalization of the process, and asking specific and detailed questions about sexual exploration and diversity (table 1 and table 2).

The AAP, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and the Society for Adolescent Health and Medicine encourage health care providers to routinely review issues of sexuality with adolescent patients [17,18]. (See "Confidentiality in adolescent health care" and "Sexual development and sexuality in children and adolescents".)

Just ask — Adolescents may not disclose their sexual orientation, identity, or behaviors to their provider unless they are asked [83,84].

In a survey of 130 youth who self-identified as lesbian, gay, or bisexual, 65 percent reported that they had not disclosed their orientation to their health care provider, although 70 percent were "out" to most people [83]. When they were asked what clinicians could do to make talking about being lesbian, gay, or bisexual more comfortable, 64 percent responded "just ask me." Nonetheless, surveys indicate that only a minority of primary care providers ask adolescent patients about sexual orientation and sexual behaviors [85-89].

Providers can ask, "Do you like boys, girls, both, or neither?" in a developmentally appropriate manner as a simple first step to asking about sexuality (table 1 and table 2). Providing examples and normalizing a range of responses may make it easier for the adolescent to disclose same-sex experiences.

The adolescent is the best person to describe and define their identity and behaviors. Many youth avoid categorization, preferring more diffuse terminology such as queer, pansexual, asexual, or fluid regarding their sexuality. What matters for most youth is that the provider asks about their personal perspective, experience, and what terminology best suits their needs.

Avoid assumptions — It is important for health care providers to avoid assumptions about sexual orientation and behaviors. Assuming that all patients are heterosexual may lead to missed opportunities for preventive screening or counseling for risk reduction. (See "Sexual development and sexuality in children and adolescents".)

It is also important that providers do not make assumptions about sexual behavior and presumptive risk based on self-labeling of sexual identity. As an example, lesbian-identified youth have a high incidence of engaging in sexual behavior with cisgender males and are at risk for unintentional pregnancy. (See 'Pregnancy prevention' below.)

Avoiding assumptions demonstrates openness and respect for sexual diversity. For nonsexual minoritized youth, it sets the expectation for tolerance. It also may provide an opportunity for the clinician to explore negative attitudes or reactions and dispel harmful myths about sexual minorities.

Normalize the process — Adolescents may have little experience discussing sexuality and sex. It is important to try to put them at ease by letting them know that the sexual history is routinely included in the medical history for adolescent patients [90].

The sexual history can be introduced by saying something like [91], "Just so you know, I ask these questions to all my adolescent patients. They are as important as the questions about other areas of your health." It is important for the clinician to explain the exceptions to confidentiality, including safety (eg, abuse, suicidal ideation) and other reproductive health needs (eg, sexuality, contraception, pregnancy, abortion) that vary by state law. Confidentiality in adolescent health care is discussed separately. (See "Confidentiality in adolescent health care".)

Ask specific questions — Detailed and specific information about partners and behaviors is important in determining strengths and risks so that risk reduction counseling can be appropriately targeted. It is important to ask about partners and behaviors in addition to sexual orientation because transgender youth may identify as gay or lesbian and because youth who identify as "heterosexual" may have same-sex attractions and behaviors [92].

The detailed sexual history can be introduced by saying something like: "I am going to be more explicit here about the kind of sex you've had and your sexual partners to better understand if you are at risk for STIs. A lot of people your age have sex with members of the opposite sex or the same sex" [13,22,91]. Asking specifically about "what parts go where" permits targeted STI screening. As examples:

●For youth involved exclusively in receptive anal sex, rectal chlamydia and gonorrhea testing is indicated but urine tests can be avoided

●For youth whose sexual behaviors are limited to kissing and fondling, urine testing for chlamydia and gonorrhea can be avoided. However, kissing may be a risk factor for oropharyngeal gonorrhea among males who have sex with males [93].

Going through a list of specific parts (eg, "Does your penis go in your partner's mouth, vagina, rectum?"; "Does your partner's penis go inside your mouth, vagina, rectum?") can help educate youth about sexual behaviors that increase their risk of STI. While youth may initially be uncomfortable discussing body parts and activities, direct and explicit conversation about behaviors can help to normalize the conversation.

In addition to information about partners (same- or opposite-sex, number), the sexual history should include [94]:

●The date of last sexual activity

●The type of sexual activity (eg, digital, oral, vaginal, anal)

●Last sexual activity without a condom

●Last sexual activity without hormonal or intrauterine birth control

●History of STIs

As part of normal sexual development, adolescents may explore/experiment with a variety of sexual behaviors. Leaving an open-ended time for an adolescent to reflect and report on their sexual experiences may be important to eliciting additional important information including: open relationships, substance use with sex, sexual enhancing medicines or devices, auto-eroticism, and other sexual alternatives.

Sexual behaviors that may be associated with acquisition of STIs, regardless of sexual orientation, include:

●Digital penetration – Digital penetration or fingering (touching or penetrating the vagina or anus with fingers) is less risky than penile vaginal or anal penetration, but is not entirely risk free.

●Oral sex – Oral sex includes kissing, licking, or sucking on the penis, scrotum, vagina, or anus (rimming). Adolescents may underestimate the risk of disease with oral sex, thinking it is entirely risk free [95]. STI transmission via oral routes is less likely than with anal or vaginal penetration, particularly for HIV [96,97], but gonorrhea, chlamydia, syphilis, herpes simplex virus type 1 and 2, and human papillomavirus can be transmitted orally. Heterosexual adolescents and older women who have sex with women rarely use barrier protection (condoms or dental dams) when engaging in oral sex [98-100], but data for sexual minoritized youth are lacking.

●Anal sex – Unprotected penile-anal sex is associated with increased risk of HIV and STI transmission [101]. Surveys indicate that between 1 to 6 percent of young males may engage in same-sex anal sex and that approximately one-half do not use condoms, particularly when under the influence of alcohol or drugs [102-107]. Data regarding anal sex among young women who have sex with women are lacking, as are data regarding anal sex among young women who have sex with men.

●Vaginal sex – Unprotected vaginal sex (whether insertive or receptive, with a penis or prosthetic [eg, hand-held or strap-on]) is associated with increased risk of STI transmission. However, the risk varies with the disease and sexual practice (eg, penile penetration or penetration with sex items) [108,109].

Counseling for risk reduction (ie, "safer sex") is discussed below. (See 'Prevention of HIV' below and 'Prevention of other STI' below.)

SCREENING AND SURVEILLANCE

STI and HIV — Screening asymptomatic adolescents for sexually transmitted infections (STIs) is performed according to the adolescent's sexual behavior rather than their sexual orientation or identity [24,94,110]. Our screening recommendations are largely consistent with those of the Centers for Disease Control and Prevention (CDC) [94].

Annual screening for chlamydia, gonorrhea, syphilis, and HIV is recommended for sexually active youth and should be initiated as soon as possible after onset of sexual activity. The sites of screening for chlamydia and gonorrhea vary depending upon the sexual behaviors (eg, rectal screening for gonorrhea and chlamydia is recommended for young men, transgender women, or transgender men who have sex with men [MSM] and who have had receptive anal sex in the preceding year) [111]. Adolescents who test positive and are treated for an STI are offered more frequent STI testing and asymptomatic screening (eg, syphilis, hepatitis C), including testing for reinfection. (See "Screening for sexually transmitted infections", section on 'Screening recommendations' and "Screening and diagnostic testing for HIV infection", section on 'Testing algorithm'.)

Testing for HIV more frequently than recommended by the CDC solely for "reassurance" of HIV-negative status, is not recommended. In a cross-sectional study of young MSM of color from a high HIV seroprevalence area, more frequent testing was not associated with safer sexual behaviors [112]. In addition, a systematic review concluded that the benefits and harms of testing gay, bisexual, and other MSM more often than annually are uncertain [113,114]. (See "Screening and diagnostic testing for HIV infection", section on 'Testing algorithm' and "Screening and diagnostic testing for HIV infection", section on 'Routine screening'.)

In addition, screening for hepatitis A and B (if not immunized) and hepatitis C may be warranted for youth who [115]:

●Are MSMs

●Have both same-sex and opposite-sex partners

●Have unprotected vaginal or anal penetrative sex

●Test positive for another STI

●Are current or past drug users

●Have been incarcerated

(See "Hepatitis A virus infection in adults: Epidemiology, clinical manifestations, and diagnosis", section on 'Epidemiology' and "Clinical manifestations and diagnosis of hepatitis B virus infection in children and adolescents", section on 'Who should be screened' and "Hepatitis C virus infection in children", section on 'Screening'.)

Adolescents with symptoms of STI (eg, urethral or vaginal discharge, dysuria, genital or perianal ulcers, regional lymphadenopathy, dyspareunia, pain with defecation or anal intercourse) should be tested as indicated [94].

HPV-associated cancer — Human papillomavirus (HPV) is associated with cervical, anal, and oropharyngeal cancer.

Cervical cancer screening usually is not initiated before age 21 years in immunocompetent women (regardless of onset of sexual activity or sex of sexual partner) [116-120]. In HIV-infected (or other immunocompromised women), cervical cancer screening is initiated upon diagnosis. (See "Screening for cervical cancer in resource-rich settings", section on 'Screening in average-risk patients' and "Screening for cervical cancer in patients with HIV infection and other immunocompromised states".)

It is important to discuss the cost-benefit ratio for cervical cancer screening in transmasculine/nonbinary youth. Transmasculine/nonbinary youth who have never had receptive vaginal penetrative sex (penile or digital) or in any way exposed to HPV are at almost no risk for cervical dysplasia or cervical cancer. In such patients, screening for cervical cancer may be initiated after age 21 years, the age at which cervical screening is typically recommended for cisgender females. Pelvic examination may be difficult and uncomfortable for individuals with gender dysphoria. It is important for the clinician to discuss the process and procedure for cervical cancer screening. Involving the patient in the plans for the pelvic examination demonstrates sensitivity to gender dysphoria and allows the patient to have some control over their care. Use of a darkened room, distraction techniques, and anxiolytics may be helpful. (See "Gender development and clinical presentation of gender diversity in children and adolescents", section on 'Role of the medical provider'.)

For affirmed female patients, there are no agreed upon guidelines for anal cancer screening or for cervical cancer screening (if they have undergone vaginoplasty that included creation of a cervix). Screening for HPV-associated cancers may have some preventive value for transgender women who use their neovagina and or anus for receptive sex. Examination and testing transgender women who have symptoms suggestive of dysplasia, cancer, or STIs (eg, bleeding, bleeding during receptive intercourse, lesions, or other concerns) is clinically indicated according to the individual's risk factors and sexual history.

MSM and HIV-infected patients with HPV are at increased risk for anal cancer, particularly if they do not receive the HPV vaccine [121]. Although screening for anal cancer with anal Papanicolaou (Pap) smears is controversial, we agree with the Infectious Disease Society of America guidelines, which recommend anal Pap tests for HIV-positive MSM, HIV-positive women with a history of receptive anal intercourse or abnormal cervical Pap test results, and HIV-positive persons with genital warts [122]. We suggest discussing with patients that anal Pap smears can be used to evaluate the anal transition zone for anal squamous intraepithelial lesions, but that evidence on screening outcomes is lacking. This issue, including how to perform an anal Pap smear, is discussed separately. (See "Classification and epidemiology of anal cancer", section on 'Epidemiology and risk factors' and "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment", section on 'Screening for anal SIL'.)

Oral sex is a risk factor for HPV-associated oropharyngeal cancers, and the risk increased with increasing number of oral sex partners [123,124]. However, screening for oropharyngeal HPV is not recommended. (See "Human papillomavirus infections: Epidemiology and disease associations", section on 'Oropharyngeal cancer'.)

IMMUNIZATIONS — Sexual minoritized youth should receive immunizations as recommended for all children and adolescents in the United States (figure 1).

Immunizations that are particularly important for sexual minoritized youth include [94]:

●Hepatitis A virus vaccine. (See "Hepatitis A virus infection: Treatment and prevention".)

●Hepatitis B virus vaccine. (See "Hepatitis B virus immunization in adults", section on 'Indications'.)

●Human papillomavirus (HPV) vaccine for both females and males; clinical efficacy for prevention of cervical and anal cancer depends upon receipt of vaccination before sexual activity. Bivalent or 9-valent vaccines are recommended for females; the 9-valent vaccine is recommended for males. The quadrivalent vaccine may be used for females or males as long as it remains available [125]. Males and lesbian-identified females are underimmunized compared with heterosexual female peers [126,127]. (See "Human papillomavirus vaccination".)

●Meningococcal vaccine (particularly important for young men who have sex with men). (See "Meningococcal vaccination in children and adults", section on 'Indications and schedules in the United States'.)

There are specific immunization recommendations for youth who are infected with HIV. (See "Immunizations in persons with HIV".)

ANTICIPATORY GUIDANCE/COUNSELING — Information obtained from the psychosocial history can be used to target anticipatory guidance and counseling depending on individual risks.

Reinforce strengths — The adolescent's strengths (eg, self-acceptance; participation in gay-straight alliance; safe or safer sex practices, such as abstinence, monogamy, consistent use of condoms, etc) should be acknowledged and reinforced [3,14].

Children and adolescents benefit from unconditional acceptance, information sharing, and limit setting. Health care providers may be the first adult to provide these supports to youth who are questioning and coming to terms with their sexual minoritized status in an intolerant environment. Providers should not underestimate the impact that their acceptance may have on sexual minoritized youth. Providers also can help sexual minoritized youth to connect with a broader network of open and tolerant health and social resources to expand the youth's support system and build resiliency. (See 'Resources' below.)

Healthy relationships — Anticipatory guidance for adolescents includes promotion of healthy dating relationships by helping patients to learn to communicate effectively about sexual beliefs, desires, and boundaries regardless of sexual orientation. Just like youth in non-same-sex partnerships, those in same-sex relationships can be exposed to intimate partner abuse. Open and frank discussion with youth about healthy conflict resolution may help sexual minoritized youth avoid abusive partnerships, or at least raise awareness of the issue. (See "Date rape: Risk factors and prevention", section on 'Anticipatory guidance'.)

Sexual minoritized adolescents also may benefit from discussing the role of family, friends, and peers as they create plans for disclosure and other healthy friendships. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Disclosure'.)

Prevention of HIV — HIV prevention should be discussed with all adolescents; young men who have sex with men (MSM) of color and young MSM who also have sex with women or identify as bisexual are at particular risk [128]. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Sexually transmitted infections'.)

●Behavioral interventions – HIV risk reduction counseling includes recommending consistent condom use for anal or vaginal intercourse and oral-genital sex. The risk of transmission varies depending upon the type of exposure and is greatest for receptive anal intercourse [101,129]. Adolescents should also be counseled that condoms lubricated with nonoxynol-9 should not be used as a lubricant during anal intercourse [130]; nonoxynol-9 can damage the cells lining the rectum, providing a potential portal of entry for HIV [131,132]. (See "Management of nonoccupational exposures to HIV and hepatitis B and C in adults", section on 'Exposure to HIV'.)

A 2008 systematic review concluded that behavioral interventions can lead to risk reduction, but additional research is necessary to determine which strategies are most effective in reducing transmission of HIV among MSM [133]. Behavioral interventions were more effective if they promoted personal skills (eg, keeping condoms available) and in populations of MSM who did not identify as gay. Additional studies and effective interventions are critically needed for young MSM, Black/African American, and Hispanic/Latino youth [134,135]. (See "The adolescent with HIV infection", section on 'Epidemiology'.)

●Pre-exposure prophylaxis – Pre-exposure antiretroviral prophylaxis (PrEP) is an effective strategy for prevention of HIV infection in HIV-uninfected young MSM and other sexual minoritized youth who are at high risk for sexually-acquired HIV (eg, engage in unprotected receptive anal sex, have multiple or anonymous sexual partners) and are committed to medication adherence and close follow-up [136]. (See "HIV pre-exposure prophylaxis".)

The United States Public Health Clinical Practice Guideline for (available from the Centers for Disease Control and Prevention) recommends that the risks and benefits of PrEP for adolescents be weighed in the context of local laws and regulations about autonomy in health care decision-making by minors [137]. A survey of 100 racially/ethnically and socioeconomically diverse urban young MSM found that self-perceived risk for HIV transmission, enjoying unprotected sex, and being in a romantic relationship were associated with PrEP uptake; barriers to PrEP included problems with access, adherence, and costs [138]. (See "Consent in adolescent health care".)

●Postexposure prophylaxis – Observational studies suggest a possible benefit of postexposure antiretroviral prophylaxis in reducing the risk of HIV infection following sexual exposure to HIV (see "Management of nonoccupational exposures to HIV and hepatitis B and C in adults", section on 'Efficacy of post-exposure prophylaxis'). Postexposure prophylaxis against HIV may be warranted within 72 hours of a high-risk exposure (eg, unprotected or condom breakage during receptive anal intercourse with an untreated HIV-infected individual). However, postexposure prophylaxis should not be offered to individuals who repeatedly engage in high-risk behaviors that would require sequential courses of antiretroviral therapy. Other considerations for providing postexposure HIV prophylaxis (eg, medication regimen, duration, etc) are discussed separately. (See "Management of nonoccupational exposures to HIV and hepatitis B and C in adults", section on 'Exposure to HIV'.)

Prevention of other STI — Sexual minoritized youth have a higher risk of sexually transmitted infections (STIs) in addition to HIV. Strategies to prevent STI may include behavior changes, chemoprophylaxis, and immunizations.

●Behavior changes – The prevention of STI in sexual minoritized youth generally focuses on the consistent and correct use of condoms and dental dams (eg, a latex or plastic wrap barrier against vaginal/anal secretions to be used during oral sex) during vaginal intercourse, anal intercourse, and oral sex. The effectiveness depends upon correct and consistent use, type of sexual behavior, and the mode of transmission. Condoms provide protection against STI that are transmitted by infected secretions (eg, HIV, gonorrhea, chlamydia, trichomoniasis) [139]. They are less effective against infections transmitted via skin and mucous membrane contact (eg, herpes simplex virus, human papillomavirus [HPV], syphilis). (See "Prevention of sexually transmitted infections", section on 'Male condom use' and "Sexual and gender minority women (lesbian, gay, bisexual, transgender, plus): Medical and reproductive care", section on 'Prevention of sexually transmitted infections' and "External (formerly male) condoms", section on 'Protection from STIs'.)

Youth also should be counseled to avoid ejaculation in the mouth and oral-genital contact if they or their partner have a genital sore or oral ulcer. Youth may rinse, swish, and spit after oral sex but should avoid brushing the teeth before and after oral sex.

Young persons who use sex toys should be counseled to wash them with hot soapy water, or other recommended cleaners specific to the device, between uses or to cover the device with a fresh condom [94]. (See "Sexual and gender minority women (lesbian, gay, bisexual, transgender, plus): Medical and reproductive care", section on 'Prevention of sexually transmitted infections'.)

Behavioral methods that require planning and follow-through (ie, having a condom available, asking a partner to use one, putting it on, and keeping it on during sex) are often difficult to use effectively and with perfect adherence. (See "Prevention of sexually transmitted infections".)

●Chemoprophylaxis – Valacyclovir prophylaxis may be offered to the affected partner in herpes-simplex virus-discordant couples. (See "Prevention of genital herpes virus infections", section on 'Chronic suppressive therapy in discordant couples'.)

●Vaccines – Sexual minoritized youth should receive immunizations for hepatitis A, hepatitis B, HPV, and Neisseria meningitidis as recommended for all adolescents. (See 'Immunizations' above.)

There are specific immunization recommendations for youth who are infected with HIV. (See "Immunizations in persons with HIV".)

Pregnancy prevention — Counseling about pregnancy prevention, including the availability of emergency contraception, is recommended for all adolescents, even those who self-identify as lesbian or gay. It is important to frame these conversations in ways that relate to risks and do not diminish the youth's sexual identity (ie, talking about birth control to young women who have sex with women without such a frame can come across as not listening or not "getting it"). (See "Contraception: Counseling and selection" and "Emergency contraception".)

Adolescents may have sexual encounters that are not predicted by their self-identified sexual orientation [140-142]. Lesbian and bisexual adolescents and young women who have sex with women may have sex with males as they explore their sexual identity. They also may engage in heterosexual dating and sexual behaviors to avoid being identified as lesbian, may engage in exchange sex, or may have coerced sexual contact [140,141,143-145]. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Unplanned pregnancy'.)

To address the possibility that an adolescent may not disclose engaging in exchange sex, or other behaviors that increase the risk of pregnancy, the provider can say: "Do you have a need for contraception? If not now, remember to use condoms. Long-acting reversible methods are the most effective, but other methods are available. If you are trying to prevent sexually transmitted infections, then we can give you some condoms to take home. If you are not using condoms or contraception, do not forget about emergency contraception. Even though it may be available over the counter, let me write you a prescription so you can always have a dose available if you need it." (See "Contraception: Issues specific to adolescents" and "Emergency contraception" and "The preconception office visit".)

Another approach is to say something like: "I work with persons who have a wide variety of sexual behaviors…lots of different parts going in different places…so if you do not intend or want a pregnancy and there is a possibility of sperm and eggs coming in contact, you need birth control. If you do want or intend a pregnancy, then we need to talk about preconceptual care, like folic acid and prenatal vitamins, avoiding alcohol, tobacco, and drugs, as well as other ways to make you ready and help you start off with a healthy pregnancy." (See "Prenatal care: Patient education, health promotion, and safety of commonly used drugs".)

Tobacco and substance use — Clinicians can assist youth who are smokers with smoking cessation and counsel those who are nonsmokers to prevent smoking initiation. (See "Management of smoking and vaping cessation in adolescents" and "Prevention of smoking and vaping initiation in children and adolescents", section on 'Smoking and vaping prevention in the primary care office'.)

Referral to a mental health provider may be warranted for sexual minoritized youth with problematic alcohol or substance use. (See 'Indications for referral' below and "Substance use disorder in adolescents: Epidemiology, clinical features, assessment, and diagnosis", section on 'Diagnosis' and "Brief intervention for unhealthy alcohol and other drug use: Efficacy, adverse effects, and administration".)

INDICATIONS FOR REFERRAL — Indications for referral of sexual minoritized youth may include:

●Referral to more appropriate colleagues is warranted for sexual minoritized youth whose clinicians are neither comfortable with their ability nor willing to become sufficiently knowledgeable to provide high-quality care to sexual minoritized youth and youth with diverse sexual behaviors.

●Referral to a mental health provider who has worked with sexual minoritized children and adolescents and respects and understands diverse sexualities may be warranted for youth with coexisting anxiety, depression, or suicidality or significant interpersonal conflicts with peers or parents.

Mental health professionals experienced in working with sexual minoritized youth can assist in developing disclosure plans and helping youth build resiliency skills to manage inadvertent "outing," bullying, rejection, and other negative responses to which sexually minoritized youth may be exposed. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Potential psychosocial and health concerns'.)

Mental health counseling may help youth who are struggling with internalized homophobia become more self-accepting.

Mental health counseling and social support may provide youth who are living in intolerant homes or communities a refuge where they can feel safe and comfortable and develop self-esteem.

●Referral to a mental health provider may be warranted for sexual minoritized youth with problematic alcohol or substance use. (See "Substance use disorder in adolescents: Epidemiology, clinical features, assessment, and diagnosis", section on 'Screening'.)

●Referral to a mental health provider or parent support groups may be warranted for parents of sexual minoritized children and adolescents who are uncomfortable with their child's sexuality. Parents may experience a range of emotions when presented with a sexual minoritized child. It is common for parents to have rage, confusion, shock, and grief. They may mourn the loss of expectations they had for their child.

●Referral for "conversion" or "reparative" therapy is never warranted; it is not effective, may be harmful (by increasing internalized stigma, distress, and depression), and is even illegal in some states [3,4,146-151].

ADVOCACY AND SUPPORT — Advocacy and support for sexual minoritized youth are discussed separately. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Support and advocacy'.)

RESOURCES — The tables provide lists of resources that may be helpful to sexual minoritized youth (table 3), parents and family members (table 4), and clinicians (table 5).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Adolescent sexual health and pregnancy" and "Society guideline links: Health care for lesbian, gay, and other sexual minority populations".)

SUMMARY

●The components of preventive health and health maintenance for sexual minoritized youth are the same as for all adolescents. Additional concerns for sexual minoritized youth include the disclosure process and the potential for stigmatization and discrimination at home, school, and in society. Privacy and confidentiality are essential. (See 'Overview' above and 'Privacy and confidentiality' above.)

●Clinicians who are neither comfortable with their ability nor willing to become sufficiently knowledgeable to provide high-quality care to sexual minoritized youth and youth with diverse sexual behaviors should refer them to more appropriate colleagues. (See 'General principles' above.)

●Components of the adolescent psychosocial history that permit targeted anticipatory guidance and counseling for risk reduction include Strengths, Home, Education and employment, Activities, Drugs and tobacco, Depression and Suicidality, Safety, and Sexuality (SHEADDSSS). It is particularly important to ask sexual minoritized youth about their family connectedness; bullying or harassment at school; use of electronic media to meet partners; depression and suicidality; safety; and specific sexual behaviors. (See 'Psychosocial history' above.)

●Accurate information about specific sexual behaviors is necessary to appropriately target risk reduction counseling (table 1 and table 2). (See 'Ask specific questions' above.)

●Annual screening for chlamydia, gonorrhea, syphilis, and HIV is recommended for sexually active youth. More frequent testing for some sexually transmitted infections (STIs) may be warranted for adolescents who test positive for an STI. (See 'Screening and surveillance' above.)

●Sexual minoritized youth should receive immunizations as recommended for all children and adolescents in the United States (figure 1). Immunizations that are particularly important for sexual minoritized youth include hepatitis A vaccine, hepatitis B vaccine, human papillomavirus vaccine (HPV), and meningococcal vaccine. (See 'Immunizations' above.)

●Anticipatory guidance for sexual minoritized youth includes reinforcement of their strengths, information about healthy dating relationships, prevention of HIV and STI, prevention of pregnancy, and counseling about tobacco and substance use. (See 'Anticipatory guidance/counseling' above.)