Version July 2025
INTRODUCTION —
The term "sexual minoritized" encompasses a variety of sexual identities that differ from cultural norms (eg, lesbian, gay, bisexual) as well as identities that defy discrete labels [1].
This topic will focus on the primary care of sexual minoritized youth who:
●Identify themselves as lesbian, gay, bisexual, pansexual, or asexual
●Are unsure (questioning) of their sexual identity and have had sexual contact with persons of the same gender or with persons of the same gender as well as persons of different genders
●Avoid discrete sexual orientation labels and have had sexual contact with persons of the same gender or with persons of the same gender as well as persons of different genders
The epidemiology and health concerns of sexual minoritized youth, gender diversity in children and adolescents, and health care for sexual minoritized adults are discussed separately:
●(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns".)
●(See "Gender development and clinical presentation of gender diversity in children and adolescents".)
●(See "Management of transgender and gender-diverse children and adolescents".)
●(See "Primary care of gay men and men who have sex with men".)
GENERAL PRINCIPLES
●Setting up the visit – General principles related to preparing the office and office staff to care for adolescent patients, including sexual minoritized youth, and discussing sexuality with adolescents are summarized in the table (table 1) and discussed in detail separately. (See "Sexual development and sexuality in children and adolescents", section on 'Discussing sexuality'.)
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 [2,3].
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 [5]. 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 experienced colleagues [6,7]. Similarly, clinicians with negative views of sexual minoritized persons based on their own cultural, religious, or personal bias should refer sexual minoritized youth to more appropriate colleagues.
●Permission, privacy, and confidentiality – Obtaining permission to discuss sexuality and reviewing privacy and confidentiality help to establish basic trust between the medical provider and the adolescent patient. Privacy and confidentiality are crucial when discussing potentially sensitive information with adolescents [8-10]. Permission, privacy, and confidentiality are discussed separately. (See "Sexual development and sexuality in children and adolescents", section on 'Permission, privacy, and confidentiality' and "Confidentiality in adolescent health care".)
●Components – The components of preventive health and health maintenance for sexual minoritized youth are the same as those for all adolescents [4,6,11-13] (see "Guidelines for adolescent preventive services"):
•Surveillance and screening of health and development
•Immunizations
•Anticipatory guidance
•Counseling with targeted health promotion and risk reduction
Additional concerns for sexual minoritized youth include discussion of:
•The disclosure process (table 2) (see "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Disclosure')
•The potential for stigmatization and discrimination at home, at school, and in society (see "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Stigmatization and minority stress')
PSYCHOSOCIAL HISTORY —
A comprehensive psychosocial history allows the clinician to assess the adolescent's strengths and potential health risks [13,14]. 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 SHEEADSSS: Strengths, Home, Education and employment, Eating, Activities, Drugs and tobacco, Sexuality, Suicidality/depression, and Safety [15,16].
●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 [12,17-21]. (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. Parents'/caretakers' caring, supportive, and positive responses to their child's sexual orientation appear to be associated with better health outcomes for sexual minoritized youth [22]. 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 [23-25].
Avoid making assumptions about caregivers' and family members' views on sexual minoritized people or their support and acceptance of the individual youth. 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 were to disclose their sexual minoritized status.
●Education and employment – When asking sexual minoritized youth about education and employment environments, it is particularly important to ask about perceived support, victimization, and absenteeism related to victimization. For example, "What is the general attitude towards lesbian, gay, bisexual, or transgender people at your school?"; "Are you being teased, bullied, or harassed at school?" [26].
Many sexual minoritized youth experience discrimination and victimization at school [27-31]. School victimization due to perceived sexual minoritized status has been associated with social isolation, low self-esteem, depression, and suicidality [32-34]. Identification of a negative school environment and knowing what resources are available at school are necessary to intervene. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'School'.)
In a 2021 national survey of 22,298 lesbian, gay, bisexual, transgender (LGBT), and queer (LGBTQ) students (13 to 20 years), 62 percent of students who were harassed or assaulted in school did not report the incident to school staff, usually because they did not believe the school staff would do anything about it; 60 percent of students who did report an incident said that no action was taken in response or they were told to ignore it [30].
Fewer sexual minoritization-related resources were available to [30]:
•Middle school students (compared with high school students)
•Students attending public or religious schools (compared with private/nonreligious schools)
•Schools located in the southern 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 [35,36]. In a survey of 119 sexual minoritized adults, those who experienced high levels of discrimination reported that their sexual orientation negatively affected their career opportunities and satisfaction [35]. 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'.)
Young people may be bullied in school due to the young person having one or more underrepresented identity-based characteristics such as being from a Black population or being gay. For example, in the 2021 Gay, Lesbian and Straight Education Network (GLSEN) survey, 50 percent of LGBTQ students reported victimization in school due to their race, ethnicity, or nationality [30]. Sexual identity itself may be less important than prior experiences of othering and discrimination due to other identities.
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).
●Eating – Eating is sometimes considered one of the additional sections of the SHEEADSSS assessment. Gay, bisexual, and transgender adolescents are all at increased risk for eating disorders (EDs) and disordered eating behaviors. Among all adults, the presence of an ED is associated with a higher odds ratio of attempting suicide [37]. A literature review published in 2020 reported that more than one-half of LGBT adolescents have been diagnosed with a full-syndrome ED during their lifetime [38]. Another 21 percent thought that they had an ED at some point during their life, and 61 percent reported engaging in at least one disordered eating behavior within the past year. There are distinct differences among LGBT adolescents related to the etiology of EDs and disordered eating. Among lesbian-identified adolescents, there are few published data, and extant literature is inconsistent. Among females and compared with heterosexuals, sexual minoritized girls and young women were more likely to report binge eating. Among gay male adolescents, research has been consistent in demonstrating higher prevalence of EDs and disordered eating compared with heterosexual males. Among transgender youth, literature draws a clear connection between stigma and discrimination to EDs and disordered eating. Proximal factors associated with EDs or disordered eating include concealment of sexual minoritized status and internalized trans- or homophobia.
Screening for ED behaviors (such as bingeing, purging, use of laxatives, or excessive exercise) is an important aspect of anticipatory guidance for LGBTQ youth so that early intervention is possible. Providers should anticipate that many ED programs may not consider the needs of sexual minoritized individuals and should take special care to avoid LGBTQ youth being further harmed by health care professionals. Considerations for transgender and nonbinary youth care within the setting of ED programs should consider inclusive environments with affirmation of gender incorporated into intake paperwork, medical care, and ongoing ED care. Specifically, transgender and nonbinary youth may have different purposes for disordered eating related to affirmation of gender compared with their cisgender and lesbian, gay, and bisexual peers [39].
●Activities – Asking sexual minoritized youth about their activities helps to assess their social connectedness, which has important implications for health outcomes [40]. 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) [41].
Ask all adolescents, including sexual minoritized youth, about use of electronic media [42] and specifically if they use electronic media for sexual purposes (eg, viewing pornography, meeting partners, online dating) [13,43,44].
Use of electronic media may be associated with benefits and risks [43,45,46]. Benefits include:
•Increased educational and social networking opportunities, possibly compensating for limited personal relationships and offline resources (especially for sexual minoritized youth without transportation, who live in rural areas, or who are not yet out to their family or local community) [47].
•Exposure to a broader array of ideas, backgrounds, and persons than is available in their immediate family or local community [43].
•Increased access to information about health (eg, STIs), sensitive or private concerns, confidentiality, or sexuality [48,49]; however, the information may be inaccurate or inappropriate [43,45].
Risks of electronic media use may include:
•Increased risk of victimization. Sexual minoritized youth are at risk for victimization by individuals they meet online [50]. 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) [51,52].
•Threats to privacy or confidentiality.
•Increased risk of cyberbullying, which can have significant and life-threatening consequences for all youth [43,45,46,53,54]. In a 2021 national survey of 22,298 sexual and gender minoritized students (13 to 20 years), 37 percent were harassed online during the school day based on their sexual orientation [55].
Perception by youth that they are supported by family and friends may be protective against cyberbullying [56].
●Drugs, alcohol, and tobacco – In population-based surveys, sexual minoritized youth are consistently at greater risk for problematic tobacco and substance use than their nonsexual minoritized peers [57-60]. Male sexual minoritized youth also are at increased risk to misuse anabolic-androgenic steroids [61]. Tobacco and/or substance use may be a marker for other behaviors that increase health risks. These may include sex in exchange for money, shelter, food, or drugs; sex with drug users; sex with more than one partner; and unprotected sex [62,63]. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Tobacco and substance use'.)
Screening youth for alcohol, tobacco, and substance use is discussed separately. (See "Screening tests in children and adolescents", section on 'Nicotine, alcohol, and substance use'.)
●Sexuality – Talking about sexuality with adolescents is discussed in detail separately. Important aspects of the discussion include normalizing sexuality and avoiding assumptions (table 1). (See "Sexual development and sexuality in children and adolescents", section on 'How to discuss'.)
Other aspects of the discussion that are particularly relevant for sexual minoritized youth include:
•Asking about sexual orientation and identity – Adolescents may not disclose their sexual orientation, identity, or behaviors to their provider unless they are asked [64,65]. Therefore, it is important to ask youth explicitly about their sexual orientation and identity. It is also important to frame these queries in a developmentally appropriate manner [66]. Younger children are usually comfortable answering questions about "crushes" on peers or media personalities. Older youth can be asked as to what gender or genders, if any, they are romantically or sexually attracted.
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 3 and table 4). Providing examples and normalizing a range of responses may make it easier for the adolescent to disclose same-gender experiences. Ask about partners and specific types of behaviors in addition to attraction [67].
The adolescent is the best person to describe and define their identity and behaviors. Many youths 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.
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 [64]. 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."
•Asking specific questions to target risk reduction counseling – Detailed and specific information about sexual behaviors and body parts of partners determines risks and strengths to target screening and anticipatory guidance. Ask about specific sexual behaviors, use of condoms and contraception, and victimization. Asking specific questions about sexual behaviors is discussed in detail separately. (See "Sexual development and sexuality in children and adolescents", section on 'Ask specific questions to assess risks and strengths'.)
Examples of how specific information about "what parts go where" affects preventive care for sexual minoritized adolescents include (see 'Sexually transmitted infections and HIV' below):
-For youth involved exclusively in receptive anal sex, rectal chlamydia and gonorrhea testing is indicated, but urine tests can be avoided. (See 'Sexually transmitted infections and HIV' below.)
-For youth whose sexual behaviors are limited to kissing and fondling, urine testing for chlamydia and gonorrhea can be avoided. However, kissing with or without oral sex may be a risk factor for oropharyngeal gonorrhea among men who have sex with men (MSM) [68].
Counseling for risk reduction (ie, "safer sex") is discussed below. (See 'Prevention of HIV' below and 'Prevention of other STI' below.)
●Depression and suicidality – Ask all adolescent patients about emotional health and suicidality. In addition to the usual challenges of adolescence, sexual minoritized youth commonly experience social isolation, low self-esteem, anxiety, depression, and suicidality [69-72].
Sexual minoritized youth report higher rates of suicidality (ideation and attempt) than heterosexual youth [73-75]. 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-gender attraction, depressive symptoms, hopelessness, symptoms of conduct disorder, and impulsivity [76-82].
Identification of depression, anxiety, and suicidality in adolescents is 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 disposition", section on 'Assessment'.)
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 "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 sexual orientation or gender identity 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 – 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 [29,83-85]. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Victimization and violence'.)
Ask sexual minoritized youth about safety and offer appropriate support and intervention as indicated [86].
•Safety at home:
-How safe or unsafe do you feel at home? In what ways have you felt unsafe because of your sexual identity or expression?
-Tell me about any situations in which you have been verbally, emotionally, physically, or sexually abused by a parent, relative, or caregiver.
-How do your caregivers respond if you share that you feel unsafe at home, in your neighborhood, or at school?
-How do your caregivers manage stress? What ways do your caregivers reprimand or punish you? For what reasons might you be reprimanded or punished?
-Some families have interactions with Child Protective Services (CPS). Tell me about any situations in which CPS was involved with your family for intervention or support.
•Safety at school or work:
-How safe or unsafe do you feel at school and/or work?
-Is your school or workplace supportive or not supportive of you? In what ways? Who can you turn to for support at school and/or work?
-How do you and your friends manage bullying and/or physical assault at school? What happens if you are the victim? Do you ever participate in bullying or physical assault of others?
-How do people in your school or workplace intervene when bullying occurs? What are the consequences when someone is bullying or physically assaulting a peer? Who do you go to for help in these situations?
-What sorts of policies does your school and/or workplace have about victimization and bullying? Has anyone been sexually inappropriate or coercive toward you at school or work?
•Safety in the community:
-What is it like to be LGBTQ in your neighborhood, sports groups, or faith organization? What sorts of words and attitudes are you exposed to in regard to how gender and sexual minoritized persons are viewed or treated in your communities?
-Do you feel safe in your neighborhood?
-Have you ever been verbally, physically, or sexually harassed by other youth or adults in your neighborhood?
SCREENING AND SURVEILLANCE
Sexually transmitted infections and HIV
●Asymptomatic youth – Screening asymptomatic adolescents for sexually transmitted infections (STIs) is performed according to the adolescent's sexual behavior rather than their sexual orientation or identity [18,87,88]. Our screening recommendations are largely consistent with those of the Centers for Disease Control and Prevention (CDC) [88].
•Annual screening for chlamydia, gonorrhea, and syphilis 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 sexual behaviors (eg, rectal screening for gonorrhea and chlamydia is recommended for people who have had receptive anal sex in the preceding year) [89]. (See "Screening for sexually transmitted infections", section on 'Screening recommendations'.)
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 'Rescreening and retesting'.)
•Human immunodeficiency virus (HIV) screening is recommended at least annually for sexually active men who have sex with men (MSM) and other youth at increased risk for HIV, including those who themselves or whose sex partners have had more than one sex partner since their last HIV test. Additional target groups for HIV screening and the testing process are discussed separately. (See "Screening and diagnostic testing for HIV infection in adults", section on 'Routine screening'.)
•Screening for hepatitis A and B (if not immunized) and hepatitis C may be warranted for youth who [90]:
-Are MSM
-Have both same-gender and different-gender 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'.)
●Youth with symptoms of STI – Adolescents with symptoms of STI (eg, urethral or vaginal discharge, dysuria, genital or perianal ulcers or other lesions, regional lymphadenopathy, dyspareunia, pain with defecation or anal intercourse) should be tested as indicated [88]. (See "Sexually transmitted infections: Issues specific to adolescents", section on 'Diagnostic testing for STI'.)
HPV-associated cancer — Human papillomavirus (HPV) is associated with cervical, anal, and oropharyngeal cancer. HPV-related cancers develop over many years when persons are chronically exposed to oncogenic HPV strains. HPV-related cancers typically do not occur in adolescence or young adulthood but in mid- to later adult years.
●Cervical cancer screening – Cervical cancer screening is not initiated before age 21 years in immunocompetent females (regardless of onset of sexual activity or sex of sexual partner) [91-95]. In HIV-infected (or other immunocompromised) females, cervical cancer screening is initiated upon diagnosis. (See "Screening for cervical cancer in patients with HIV infection and other immunocompromised states".)
●Anal cancer screening – MSM and HIV-infected patients with HPV are at increased risk for anal cancer, particularly if they do not receive the HPV vaccine [96]. Although screening for anal cancer with anal Papanicolaou (Pap) smears is controversial, we agree with the Infectious Diseases Society of America guidelines, which recommend anal Pap tests for HIV-positive MSM, HIV-positive females with a history of receptive anal intercourse or abnormal cervical Pap test results, and HIV-positive persons with genital warts [97]. 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 "Anatomy, pathology, epidemiology, and risk factors of anal cancer", section on 'Epidemiology' and "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment", section on 'Screening for anal SIL'.)
●Oropharyngeal cancer – Oral sex is a risk factor for HPV-associated oropharyngeal cancers, and the risk is increased with an increasing number of oral sex partners [98,99]. However, screening for oropharyngeal HPV is not recommended because the prevalence is low and available biomarkers have low sensitivity [100,101]. (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). There are specific immunization recommendations for youth who are infected with HIV. (See "Immunizations in persons with HIV".)
Immunizations that are particularly important for sexual minoritized youth include [88]:
●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 initiation of sexual activity. (See "Human papillomavirus vaccination".)
●Meningococcal vaccine (particularly important for young men who have sex with men [MSM]). (See "Meningococcal vaccination in children and adults", section on 'Indications and schedules in the United States'.)
In addition to the above vaccines, people with behavioral risk (eg, MSM) or HIV should also receive the mpox vaccine. (See "Treatment and prevention of mpox (formerly monkeypox)", section on 'Persons at risk for community acquired infection'.)
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 genders and sexualities alliances; safe or safer sex practices, such as abstinence, monogamy, consistent use of condoms) should be acknowledged and reinforced [6,10].
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 learn to communicate effectively about sexual beliefs, desires, and boundaries regardless of sexual orientation. Youth in all types of dating relationships can be exposed to adolescent relationship 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 "Adolescent relationship abuse including physical and sexual teen dating violence", section on 'Universal education and anticipatory guidance'.)
Sexual minoritized adolescents may also 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 Black and Latin American men who have sex with men (MSM) and young MSM who also have sex with females or identify as bisexual are at particular risk. (See "The adolescent with HIV infection", section on 'Epidemiology' and "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 [102,103]. Adolescents should also be counseled that condoms lubricated with nonoxynol-9 should not be used during anal intercourse [104]; nonoxynol-9 can damage the cells lining the rectum, providing a potential portal of entry for HIV [105,106]. (See "Prevention of sexually transmitted infections", section on 'Male condom use'.)
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 [107]. 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 or African American, and Hispanic or Latin American youth [108,109]. (See "The adolescent with HIV infection", section on 'Epidemiology'.)
●Pre-exposure prophylaxis – Pre-exposure antiretroviral prophylaxis (PrEP) is an effective method for prevention of HIV infection in HIV-uninfected young MSM and other sexual minoritized youth who are at risk for sexually acquired HIV [110].
Risk factors include condomless anal or vaginal sex in the past six months plus any of the following:
•One or more sex partners of unknown HIV status
•Partner with HIV (unknown or detectable viral load)
•Gonorrhea, chlamydia, or syphilis infection in the past six months (if sex is anal receptive or insertive)
•Gonorrhea or syphilis infection in the past six months (if sex is vaginal receptive or insertive)
The United States Public Health Clinical Practice Guideline on using PrEP for the prevention of HIV infection recommends PrEP for adolescents who report sexual or injection behaviors that increase the risk of contracting HIV [111]. Clinicians who provide PrEP to adolescents must be aware of local laws and regulations about autonomy in health care decision-making by minors (available from the Centers for Disease Control and Prevention [CDC]) [112].
A survey of 100 young MSM from New York City (two-thirds of the study population were Black, Hispanic or Latin American, Asian/Pacific Islander, and multiracial men) 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 [113]. (See "Consent in adolescent health care" and "HIV pre-exposure prophylaxis".)
●Postexposure prophylaxis – Observational studies suggest a benefit of postexposure antiretroviral prophylaxis in reducing the risk of HIV infection following sexual exposure to HIV [114-126]. Postexposure prophylaxis against HIV is recommended within 72 hours of an exposure (eg, receptive or insertive anal or vaginal sex with an individual of unknown or positive HIV status, high-risk sexual exposure [eg, sexual trauma, mucosal tear]). 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) are discussed separately. (See "Management of nonoccupational exposures to HIV and hepatitis B and C in adults", section on 'HIV post-exposure management'.)
Prevention of other STI — Sexual minoritized youth have a higher risk of sexually transmitted infections (STIs) in addition to HIV. Strategies to prevent STI 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 STIs that are transmitted by infected secretions (eg, HIV, gonorrhea, chlamydia, trichomoniasis) [127]. 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 "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 [88].
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 – Vaccines recommended for sexual minoritized youth are discussed above. (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. As an example, talking about birth control with 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 [128,129]. 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 [128,130,131]. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Unplanned pregnancy' and "Gender development and clinical presentation of gender diversity in children and adolescents".)
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 STIs, 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: Overview of issues specific to adolescents" and "Emergency contraception" and "The prepregnancy 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). If you do not want a pregnancy and there is any possibility of sperm and eggs coming in contact, you need birth control. If you do want a pregnancy, then we need to talk about preconception care, like taking folic acid and prenatal vitamins; avoiding alcohol, tobacco, and drugs; and identifying 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".)
A text messaging-based healthy sexuality program, Girl2Girl, has been developed to reduce teen pregnancy risk among lesbian and bisexual teens. A 20-week trial of Girl2Girl conducted with 948 participants (99 percent cisgender girls) demonstrated a small but statistically significant increase in use of condoms and other birth control methods at 6, 9, and 12 months [132].
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, suicidality, or significant interpersonal conflicts with peers or caregivers.
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 caregiver support groups may be warranted for caregivers of sexual minoritized children and adolescents who are uncomfortable with their child's sexuality. Caregivers may experience a range of emotions when presented with a sexual minoritized child, including 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 [4,6,55,133-138].
RESOURCES —
The tables provide lists of resources that may be helpful to sexual minoritized youth (table 5), caregivers and family members (table 6), and clinicians (table 7).
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
●General principles – 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, at school, and in society. Privacy and confidentiality are essential. (See 'General principles' above.)
Clinicians who lack comfort with or knowledge about the needs of sexual minoritized youth and youth with diverse sexual behaviors should refer patients to more experienced colleagues for the provision of high-quality care.
●Psychosocial history – Components of the adolescent psychosocial history that permit targeted anticipatory guidance and counseling for risk reduction include (see 'Psychosocial history' above):
•Strengths
•Home, particularly family connectedness
•Education and employment, particularly bullying or harassment
•Eating
•Activities, including use of electronic media to meet partners
•Drugs and tobacco
•Sexuality and specific sexual behaviors (table 3 and table 4)
•Depression, anxiety, and suicidality
•Safety at home, at school, and in interpersonal relationships
●Screening and surveillance – Annual screening for chlamydia, gonorrhea, and syphilis 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 for sexually transmitted infections", section on 'Rescreening and retesting'.)
HIV screening is recommended at least annually for sexually active men who have sex with men (MSM) and other youth at increased risk for HIV, including those who themselves or whose sex partners have had more than one sex partner since their last HIV test. (See 'Screening and surveillance' above.)
●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 hepatitis A vaccine, hepatitis B vaccine, human papillomavirus (HPV) vaccine, meningococcal vaccine, and, for those who are behaviorally at risk (eg, MSM), mpox vaccine. (See 'Immunizations' above.)
●Anticipatory guidance – 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.)
