Promoting mental well-being in LGBTQ youth

January 31, 2017|Pediatrics

For many the beginning of a new year is a time to set goals and resolutions for the upcoming year. Often these resolutions are related to health, for example, quit smoking, work out more, lose weight. It is sometimes easy to overlook mental health and well-being as an integral part of overall wellness. This month’s column will focus on how as pediatric providers we can help promote the mental well-being of our patients in practice.

Mental health problems are a significant cause of morbidity and mortality in youth. In 2014, suicide was the second leading cause of death for all youth 10-14 years and 15-24 years.¹ While most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) persons live healthy, happy lives, LGBTQ youth are at disproportionate risk for mental illness, probably related to lack of support and to stigma related to their sexual minority and gender minority identities. Studies suggest that LGBTQ youth have suicidality rates two to five times higher than their heterosexual cisgender peers.^2,3,4

As pediatric providers, we can play an important role in screening for mental health concerns and identifying these concerns early so they can be addressed and treated. Pediatric providers also may be the first resource patients and families come to for assistance with mental health concerns. A recent article by Adelson et al. in Pediatric Clinics of North America discusses how the principles of care outlined by the American Academy of Child and Adolescent Psychiatry for the care of LGBT youth can be applied to pediatric practice.^5,6 The principles and how they can be applied will be briefly reviewed here:

• Principle 1. A comprehensive diagnostic evaluation should include an age-appropriate assessment of psychosexual development for all youths.

While pediatric providers are unlikely to perform a comprehensive mental health diagnostic evaluation, psychosocial development should regularly be assessed at well visits. It may not be readily apparent which youth are struggling with development of their sexual and gender identity. Nonassuming questions regarding development in theses domains should ideally be integrated into the psychosocial assessment. For example, begin a sexual history by asking, “Are you romantically attracted to males, females, both, or neither?”

• Principle 2. The need for confidentiality in the clinical alliance is a special consideration in the assessment of sexual and gender minority youth.

Confidentiality is important when talking to any youth about their sexual and gender identity. LGBTQ youth in particular may have concerns of family or provider rejection, and they may look for cues that they can safely discuss their sexuality or gender identity without fear of being judged or shamed. Clinicians should be aware of confidentiality practices for minors when discussing these issues. Potential risks of premature disclosure to family and support systems, such as rejection or alienation, also should be considered.

• Principle 3. Family dynamics pertinent to sexual orientation, gender nonconformity, and gender identity should be explored in the context of the cultural values of the youth, family, and community.

Families can have a variety of responses to their child’s sexual minority or gender minority identity, ranging from acceptance to rejection, with some youth being forced to leave home. Many families need to alter their ideas and expectations for a child after their child comes out, and this can lead to feelings of loss and grief accompanied by feelings of anxiety, anger, shame, and guilt.⁵ Over time, however, the majority of families become affirming and supportive and are not distressed.⁷ Recognizing that family support reduces negative health outcomes for youth, providers should aim to support and preserve positive family relationships when possible. This may involve education and support for families as well as youth. It is important to be aware that sexual and gender minority youth who are also members of ethnic minorities may face additional challenges.

• Principle 4. Clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased psychiatric risk.

Providers should recognize that LGBTQ youth are at disproportionate risk of bullying, suicide, substance use, high-risk sexual behaviors, running away, and becoming homeless. Providers should assess for these risks and address them as appropriate.

• Principle 5. Clinicians should aim to foster healthy psychosexual development in sexual and gender minority youth, and protect these individuals’ full capacity for integrated identity formation and functioning.

Providers should support healthy youth development and self-discovery, recognizing that there is a spectrum of sexual and gender identities, with the goal of helping youth achieve their full developmental potential.

• Principle 6. Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and attempts to do so may be harmful.