David S. Reitman, MD, MBA. Adolescent medicine specialist, Georgetown University Hospital Assistant professor, Georgetown University School of Medicine Medical Director, American University Student Health Center Washington, DC.
Dr. Reitman has disclosed that he has no relevant relationships or financial interests in any commercial company pertaining to this educational activity.
CCPR: What does the average child psychiatrist, who may not have a lot of experience in this area, need to know about treating lesbian, gay, bisexual, and transgender (LGBT) youth?
Dr. Reitman: I have been talking about this topic for about 20 years now, since I was a medical student. In that time, there has been a big shift in that a lot more kids are coming out about their sexuality and at earlier ages. Ten to 15 years ago, many kids were coming out in college, if not into their early to mid-20s. Now we are seeing a trend where a lot more of these kids are coming out in high school, both to themselves, as well as to their parents and friends. Sometimes it is even earlier when they are in middle school.
CCPR: Why is that?
Dr. Reitman: I think that a lot of this has to do with images in society and in the media. There are many more role models. However, there is variation between parts of the country that tend to be more conservative versus those that are more liberal about these issues. It still may be difficult for LGBT youth who are growing up in conservative rural areas to be able to find resources or get support either from friends, for their families, or to meet other kids who are like them. That is in a contrast with large, metropolitan cities such as Washington, DC or New York where it may seem as if every school has a gay-straight alliance. While we think things have changed so much and are so much better, this may not be universally true for kids throughout the country. I see a lot of kids in my practice who are still dealing with the emotional baggage from their negative experiences coming out at a younger age in high school.
CCPR: Are there other things child psychiatrists need to be aware of?
Dr. Reitman: One of the big things is the language you use. Many LGBT youth really are not ready to “label” themselves as “L, G, B or T”, and if you assign them to a label they may bristle about it. They may not respond or may think ‘this person doesn’t understand me or the issues that I am dealing with’. When interviewing kids and trying to get their history, I recommend that the psychiatrist, therapist, or physician ask something more along the lines of: “When you think about people, who are you generally attracted to? Are you attracted to guys, girls, or both?” When broaching the conversation with kids who may be struggling with their sexual identity or gender identity, we need to look at the language we are using and make sure that we are not over-labeling to exclude anyone or making assumptions.
CCPR: Is it also true that many times they don’t know how to describe themselves?
Dr. Reitman: It’s interesting. Twenty years ago, the Minnesota Youth Risk Behavioral Survey demonstrated that only about 30% of kids who had predominant attractions and sexual activity with members of the same gender would actually label themselves as GLB. In 2009, that number was just about 50%. Therefore, there are a lot of kids who have these feelings but aren’t sure what they mean and/or are not ready to label themselves. I helped write a position paper for the Society for Adolescent Health and Medicine with recommendations on how to care for LGBT adolescents (Society for Adolescent Health and Medicine, J Adolesc Health 2013;52(4):506–510; http://bit.ly/1uiDyTT).
CCPR: What kind of advice can you give to a psychiatrist who is treating a younger kid who begins to realize he or she is not straight and needs help navigating that?
Dr. Reitman: First, it’s important to identify if a kid may not be conforming to what is considered a “norm” for the family (in terms of the way the kid is acting, or dressing, or his interests). If this is perceived as an “elephant in the room,” it is okay to bring it up with the parents and ask, “Are you concerned that your child may be gay or may end up being gay?” A psychiatrist shouldn’t be afraid that the parents will think that you are trying to put ideas into their head or their kid’s head. Many times the parents will be relieved that someone is at least validating their concerns. This may also be good time for the psychiatrist to start working through some of the parents’ issues with homosexuality, so if three years down the road, the child does decide to come out, the parents have some grounding to be able to deal with this. It is okay to talk about it with younger kids because kids are coming out younger and younger.
CCPR: Do you find that being gay is still seen by some as an illness?
Dr. Reitman: I gave a grand rounds on this topic about five years ago and afterwards one pediatrician asked, “You’ve presented all this really interesting information. How do you fix this? How do you treat this?” I then realized that there is a fundamental fact that needs to be emphasized: These kids are normal in every way. When you talk about LGBT youth having higher incidences of depression, anxiety, homelessness, and high-risk sexual behavior, it is not a function of them being gay, lesbian, bisexual, or transgender; rather, it’s a function of society. It is society’s non-acceptance that actually causes them to demonstrate these morbidities, not their innate sexual orientation. Most importantly, if I was going to make one take-away comment to psychiatrists, it is about the damage caused by reparative therapy. [Ed note: Also known as conversion therapy or reorientation therapy, this is a range of treatments that aim to change sexual orientation from homosexual or bisexual to heterosexual.] I have seen many of my college-aged patients go through it and they are so damaged and traumatized. The trauma is frequently associated with PTSD, with flashbacks, with self-loathing. The American Psychiatric Association, the American Psychological Association, and the American Academy of Pediatrics have all taken positions against it. It can’t be emphasized enough that reparative therapy is never appropriate for these kids.
CCPR: In the case of a kid transitioning their gender, what if you have one parent who is supportive and one who is not dealing with it very well? How do you navigate that?
Dr. Reitman: There is no one road map for how to have a family deal with a child who has decided to transition their gender. And as difficult as it was 20 years ago for families to deal with their children coming out as gay, lesbian, or bisexual, I think it is even more difficult with transgender because gender is such a fundamental part of how people define themselves. I think that it really is important for both parents to work on this in family therapy. It is not an easy process, but if the parents really love their kids, they will do this for them and learn to accept and love them regardless of their gender.
CCPR: What other actions can doctors take, as well as parents or schools to work on these issues?
Dr. Reitman: Change happens at the local level, at the family level. In the past there was this idea that when LGBT kids had difficulty with their family the best thing was to remove them from the family and get them into a ‘retreat’ with other kids who were gay. In our position paper, we referenced work that researcher Caitlin Ryan has published over the last couple of years with the Family Acceptance Project. Dr. Ryan’s data showed convincingly that the best outcomes occur when kids stay at home with their families, even if the parents don’t understand their child’s sexual orientation or gender identity. When the parents can show their love rather than disowning the child, that child is going to do tremendously better than the one who is going to be in some kind of program or foster care.
CCPR: Are there resources a pediatrician or psychiatrist can recommend to parents or families, perhaps web-based support or good national support groups?
Dr. Reitman: In terms of national support groups, I think PFLAG [Parents, Families, and Friends of Lesbians and Gays] leads the way in terms of being able to provide support to the families (http://community.pflag.org/). Beyond their online presence, they will actually hook parents up with other families in their general area who are dealing with similar kinds of issues. The Human Rights Campaign, which is a political organization, also has a lot of resources for families and parents.
CCPR: What are some of the medical issues we should be aware of when working with this population?
Dr. Reitman: From the medical standpoint, you are counseling kids about issues such as what is safe when it comes to sexual activity and what they need to do to test for sexually transmitted infections. Those are significant medical issues that don’t get addressed because a lot of times providers don’t know how to counsel these kids. For example, young gay male adolescents who are sexually active don’t realize that the Centers for Disease Control and Infection (CDC) recommends they be tested for sexually transmitted infections, including a throat swab for gonorrhea, a rectal swab for gonorrhea and chlamydia, and a blood test for syphilis and HIV on an annual basis. They don’t think about the fact that they can have an STD [sexually transmitted disease] in other places besides the genital area. On the flip side, young women who are having sex with women, may get the message that because they are a lesbian they don’t have to worry about HPV or cervical cancer and don’t need to have Pap smears. In reality that is not true either. People have sex with lots of different kinds of partners, and youth never know what exactly somebody has done in their past. So you really do have to make sure that, when you are talking to your patients, you have an honest discussion and that you are comfortable talking about all different things when it comes to sexual orientation and behaviors. Frankly, adolescents will pick up on discomfort in a heartbeat. They know when their provider is not comfortable and they will take advantage of that or just avoid the conversation at all.
CCPR: Are there repercussions from the failure to provide effective counseling?
Dr. Reitman: Well, HIV rates are slowly starting to go up again in young men. You definitely see that happening in young African American men. There is a significant increase over the last five to 10 years in high-risk sexual behavior and having receptive anal sex without condoms, which is otherwise known as “bare backing.” I think a lot of this is because these kids don’t have the information they need to realize that HIV is not curable. They hear in the news about cures and treatments. For adolescent, concrete thinkers, either there is a cure or there is not a cure. They don’t think about the bigger picture of what is going on here.
CCPR: People are living longer with HIV and it is now seen as a chronic rather than a terminal illness. Do you think kids don’t realize this is a virus that you carry your entire life and not everyone is as fortunate as some public figures with HIV who appear healthy and doing very well?
Dr. Reitman: They don’t see that the medication used to treat HIV can lead to pancreatitis, hepatitis, rashes, fever, nausea, and vomiting. They don’t see how often people have to go and get their blood work done. They are not seeing the stigma about HIV that is still present, which can affect their ability to form new relationships. Again, these are adolescents who frequently don’t see the big picture when it comes to HIV or healthy decision making.
CCPR: Thank you for sharing your knowledge with us, Dr. Reitman.
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