Children and adolescents who are gay, lesbian, or bisexual, and those with gender nonconformity or gender discordance may be affected by negative attitudes, putting them at risk of certain mental health conditions. The American Academy of Child and Adolescent Psychiatry (AACAP) has released practice principles to consider when caring for these patients.

Practice Principles

DIAGNOSTIC EVALUATION

Children and adolescents should receive a comprehensive, age-appropriate diagnostic evaluation that includes psychosexual development. Questions about sexual feelings, experiences, and identity or gender role behavior and gender identity may be helpful. The history should be approached in a nonjudgmental way, and without assumptions. If the initial evaluation shows that the patient is having issues with sexual orientation or gender identity, these issues should be addressed further.

CONFIDENTIALITY

Although confidentiality is important with all patients, it is a special consideration in children and adolescents with sexuality or gender issues because they require a safe, accepting environment in which they can explore their identities. Physicians should be familiar with standard confidentiality practices for all patients who are minors and also consider the implications of prematurely disclosing a patient's sexual orientation or gender identity to family members (e.g., rejection, alienation). It may be appropriate to let the patient set the pace.

FAMILY DYNAMICS

The reaction of families to children or adolescents who are homosexual, bisexual, or transgender varies. Most parents experience distress initially, even if they later support their child. Youths who are rejected by their parents can have low self-esteem and low capacity for intimacy, and are at risk of homelessness, substance abuse, depression, and suicide. Physicians should assess the parents' ideas about what is acceptable, their cultural background (some ethnic or religious groups may be more likely to reject nontraditional lifestyles), and any misconceptions they have about homosexuality. Physicians should also attempt to help patients overcome feelings of shame and guilt, and preserve family relationships when possible.

COMMON RISK FACTORS

Physicians should ask patients about factors that are common in homosexual, bisexual, and transgender youths that may increase their psychiatric risk. These risk factors include bullying, suicide, high-risk behaviors, substance abuse, and sexually transmitted diseases.

Patients may benefit from resources to help them cope with peer harassment. School programs, such as no-tolerance policies, have been effective. Family treatment may be useful if the harassment is coming from family members. Psychotherapy and environmental interventions (e.g., advocacy with schools and other community entities) may also be considered.

The risk of suicidal thoughts and suicide attempts may be especially high following a same-sex experience, but before self-acceptance of homosexuality. This risk is highest in gay males who are gender-variant as children. Preventive factors include family connectedness, adult caring, and school safety.

Factors that promote high-risk behavior among gay and lesbian youth include maladaptive coping with peer, social, and family ostracism; emotional and physical abuse; and neglect. Physicians should monitor for these risks or provide anticipatory guidance when appropriate. Positive coping skills can lower the risk.

HEALTHY PSYCHOSEXUAL DEVELOPMENT

An important clinical goal in the care of homosexual, bisexual, and transgender youth is protecting their opportunity to achieve full developmental potential. The goal is to support healthy development and honest self-discovery, without making premature conclusions about the patient's sexuality or gender identity.

THERAPY

Therapeutic interventions can influence acceptance by the patient and family members. Family rejection and bullying are appropriate focuses of therapy, rather than the patient's current or future sexual orientation. There is no evidence that therapy to influence sexual orientation is effective, and it may be harmful.

GENDER DISCORDANCE

Most children display some behaviors that adults would consider a departure from typical gender roles. It is important to distinguish children who display only a variation in gender role behavior from those who also display gender discordance. A clinical interview using the Diagnostic and Statistical Manual of Mental Disorders is the preferred method for making a diagnosis. Disorders of sexual development are important in the differential diagnosis, and can be addressed with endocrinologic treatment.

Proposed goals of treatment for children with gender discordance include reducing the desire to be the other sex, reducing social ostracism, and reducing psychiatric comorbidity. There are no randomized controlled trials of any treatment. Recent treatment strategies based on uncontrolled case series focus on parent guidance and peer group interaction. Because of the lack of evidence and potential risks, more research is needed before treatment can be recommended. Similarly, there are no data from controlled studies regarding sending children with gender discordance to school in their desired gender. Decisions must be made based on clinical judgment.

Sometimes, gender discordance presents in adolescence or adulthood. One goal of treatment for adolescents is to help them make developmentally appropriate decisions regarding sex reassignment, reducing risks of reassignment, and managing associated comorbidities. However, reassignment is ideally delayed until adulthood. Transgender youth may be at risk of hormone misuse.

LIAISON WITH COMMUNITY ENTITIES AND OTHER HEALTH CARE PROFESSIONALS

Physicians should be prepared to act as liaison with schools, community entities, and other health care professionals. The beliefs and attitudes of the patient's social systems should be explored, although some persons in the patient's social system may not be aware of the patient's sexual identity. Interventions to enhance support may be considered if appropriate and with the patient's consent. As consultants, physicians may choose to advocate for policies and legislation in support of nondiscrimination against those who are homosexual, bisexual, or transgender.

COMMUNITY AND PROFESSIONAL RESOURCES

There are many community-, school-, and Internet-based resources to help youths with sexual or gender identity issues. Physicians can also obtain information through professional organizations, such as the AACAP (http://www.aacap.org), the American Psychiatric Association (http://www.psych.org), the Lesbian and Gay Child and Adolescent Psychiatric Association (http://www.lagcapa.org), and the Association for Gay and Lesbian Psychiatrists (http://www.aglp.org).