Introduction:
Gay, lesbian, bisexual and transgender youth face many unique risks and
specific health issues. These youth are at greater risk for physical abuse, school
and other problems, including poor body image, eating disorders, being bullied,
running away from home, depression, suicide, chemical dependency, and STDs
including HIV (3). It is important for physicians to be able to identify these
adolescents in order to provide guidance and appropriately address their health
needs. This requires informing patients that the doctor’s office is a safe
environment, creating privacy and informing patients of confidentiality, and
asking screening questions. In 1998 two studies were completed to address this
topic. One survey self identified gay, lesbian, and bisexual youth while the other
reported on pediatricians (1,2). Allen et al. surveyed 102 self identified GLB
individuals between the ages of 18-23 years about their healthcare experiences
when they were between the ages of 14-18. They found that “78% of the
subjects never discussed their sexual orientation with their healthcare provider
but desired to do so.” The identified obstacles were a lack of understanding
confidentiality and fear of parents being informed, discussing their sexual
orientation in front of parents, fear of judgmental responses by healthcare
providers, not being asked, and a lack of pamphlets or other visual aids
indicating that the office was a safe zone (1). The study by East and Rayess was
a cross-sectional survey of 200 Washington DC area pediatricians. Of the 60
pediatricians responding, 68% did not include sexual orientation in a sexual
history at any age and 90% had reservations about addressing sexual
orientation. The major reasons for reservations were “do not know how to ask
the question” and “not knowing enough about the issues.” Little is known about
more recent physician practices and there is no data about the practices and
views on sexual orientation of pediatricians in Connecticut. This study surveyed
Connecticut pediatricians to examine the barriers and current trends in the
identification of GLBT adolescents.
Methods:
True Colors is an organization dedicated to creating a world where all
sexual orientations and gender identities are valued and affirmed. They provide
education, mentoring and advocacy. This research was conducted with their
collaboration. The survey, cover letter and a prepaid, pre-addressed return
envelope were included in a packet and information guide on CD listing
community resources. This was sent to all Connecticut pediatricians identified
through the mailing list of (n=550) in the fall of 2007. The survey included
information about physician demographic characteristics, practice setting,
experience with patients who initiate discussion of GLBT issues, sexual
orientation history taking and barriers to identifying GLBT adolescents. Many of
the questions about barriers were adapted from the work of Allen et al. (1998)
and East and Rayess (1998). The questionnaire contained multiple choice, Likert
responses, yes/no, and open-ended questions (See survey in Figure 1.). Data was
entered in Excel, recoded and analyzed in SPSS V. 15.
Special Issues Final Report, June 2008. Michelle Aubin, all rights reserved

 Results:
Demographic Characteristics:
89 Connecticut pediatricians responded to the survey representing a return rate
of 16.4%. The responding pediatricians varied in age from 26 to 82 and the
number of years in practice ranged from 0 (first year in practice) to 55. Most of
the respondents were female (60%). The location of practicing physicians was
evenly divided between urban, 49%, and non-urban, 51%.
Practice Settings: Most practice populations were predominantly white (57%).
The predominant type of patient insurance was “mostly private” by 43%
compared to public, self pay or mixed. Thus, there was a fairly equal distribution
of responding pediatricians of all ages, years in practice, location, patient
ethnicity within the practice and patient insurance. (Table 1)
Conducting Social and Sexual History:
Talking with the patient alone. The majority (75%) reported that they ask
guardians to leave once a child reaches a certain age. The age of initiating an
interview with the child ranged from 11 years to 16 years with 13 years as the
mode (42%) and 11 to 13 years representing the majority of responses at 86%.
The rest (25%) of pediatricians do not make the determination based on age, but
either ask the patient in front of the guardian, ask the guardian to leave if they
suspect that the patient has issues they’d like to keep from their guardians, or
do not ask guardians to leave.
Confidentiality. The majority (74%) of pediatricians discussed confidentiality
with every patient, the remainder only discussed confidentiality when they
thought the patient might be engaging in risky behaviors; only one respondent
indicated that they do not discuss confidentiality with patients.
GLBT patients. In response to the question “approximately what percentage of
your patients have told you that they are questioning their sexual orientation or
that they identify as gay, lesbian, bisexual, or transgender?” most (65%) said
none and the rest said <5%.
Sexual History. The majority of physicians (87%) said that they ask every patient
about sexual activity once they become a certain age. Of those who asked at a
certain age, the age ranged from 11 to 16 with 13 being the most common
(34%), 67% asked between the ages of 11 to 13 and 33% asked between ages
14-16. The 13% of pediatricians who did not ask every patient once they
reached a certain age only asked patients who seem like they might be sexually
active.

Special Issues Final Report, June 2008. Michelle Aubin, all rights reserved

 Sexual Orientation. Almost half of the pediatricians (49%) said they ask every
patient about sexual orientation/gender identity (questioning or gay, lesbian,
bisexual, or transgender) once they become a certain age. The age of initiating
this question ranged from 11 to 16 years with 13 years being the most common
(19%), 11-13 (62%) and 14-16 (37%). Slightly over half (51%) responded that
they either do not ask any patient about sexual orientation or gender identity
(21%) or only ask patients who seem gay/lesbian/bisexual/transgender (25%).
Asking the questions. The majority (76%) of pediatricians reported always using
gender-neutral questions (strongly agree/agree). The remainder 24% reported
that they did not (disagree or strongly disagree).
A third (34%) of pediatricians said they have a specific phrase/question that they
use to ask adolescent patients if they are questioning/gay/lesbian/bisexual. The
phrases varied widely, but the most common was “do you have sex with men,
women, or both” while some asked if they were “interested romantically in boys,
girls, or both.” The majority (69%) said that they had no reservations about
discussing issues of sexual orientation/gender identity with adolescents. Of the
respondents who had reservations, 48% said this was because they did not know
how to ask the questions, 21% thought that asking might offend the patients,
and other responses were not knowing enough about GLBT population needs,
questions, or resources, were afraid of offending guardians, or felt they did not
have enough time.
Office environment. In response to the question of whether they had any visual
cues in the office to suggest that the office is a safe place to discuss issues of
sexual orientation/gender identity, 98% said no.
Knowledge about GLBT issues. In response to the statement, “I am
knowledgeable about gay, lesbian, bisexual, and transgender specific health,”
64% said they either strongly agree or agree. Respondents were asked what
they would like to learn in order to provide better care for this population. The
three most common responses were how to ask the questions (75%), community
resources (70%), and specific health issues in this population (83%)(multiple
responses allowed).
Physician Practice Characteristics and Social/Sexual History Taking
There was a clear and overlapping relationship between practice characteristics
(ethnicity, urban/non, and insurance status of patients) and timing of taking a
sexual history. Of the 87% of pediatricians who asked about sexual activity once
the patient becomes a certain age, those with mostly non-white patients were
more likely to ask about sexual activity at a younger age (p=0.021). patient
insurance type and the age that the patient was asked about sexual activity
(p=0.022) and between the location of the pediatrician’s practice and the age
that the patient was asked about sexual activities (p=0.014). Pediatricians with
Special Issues Final Report, June 2008. Michelle Aubin, all rights reserved

 “mostly white” patients, “mostly private insurance,” and a “non-urbansuburban/rural” practice asked about sexual activity at an older age than
pediatricians with “mostly non-white,” “mostly non-private insurance-public/self
pay,” and “urban” location of practice asked about sexual activity (Table 2).
Of the pediatricians that ask patients about sexual orientation/gender identity,
there is a significant difference between patient insurance and the age that the
patient is asked about these issues (p=0.029). Pediatricians with patients that
have “mostly private insurance are more likely to ask about these issues at an
older age (14-16 years) than pediatricians with patients that have “mostly nonprivate-public/self pay” insurance (11-13 years)(Table 3).
Discussion:
For many years, pediatricians have struggled with how to manage the
issues of sexual orientation and gender identity. Studies have shown that the
gay, lesbian, bisexual and transgender youth face many specific health issues
that are unique from their heterosexual peers (3). Therefore, it becomes
important to identify these individuals in order to address their health needs.
The 89 CT pediatricians who returned the surveys represented a broad
distribution of age, years in practice, sex, and location of practice, patient
ethnicity, and patient insurance. Because the response rate was low (less than
20%) there may have been a selection bias towards pediatricians who are more
comfortable and experienced with GLBT issues. Also, there may be bias toward
socially acceptable responses and thus an under-reporting of behaviors, which
may not be supportive of GLBT health. However, if these results are skewed
toward more GLBT-friendly responses, it only makes the findings more
compelling.
The majority (70%) of the responding pediatricians reported that less than
5% of their patients had told them that they are questioning or identifying as
gay, lesbian, bisexual, or transgender and 22% said that none of their patients
had ever told them this. Although there are few studies documenting the
percentage of adolescents who are questioning or identify as GLBT, the Allen et
al. study found that 78% of adolescents who self identified as gay, lesbian or
bisexual never discussed their sexual orientation with their health care provider,
although they wanted to discuss the topic (2). It can be assume that even more
adolescents are questioning but have not identified as GLBT. This suggests that
the majority of pediatricians who said they don’t have any patients who are
questioning or identify as GLBT have failed to identify these patients. It most
likely does not represent the true reality.
There are many barriers to patient willingness to disclose their questioning
or GLBT identity. The first barrier is complete lack of visual cues, which would
indicate that the pediatrician’s office is a safe zone for discussing such issues, as
Special Issues Final Report, June 2008. Michelle Aubin, all rights reserved

 demonstrated by the fact that almost none of the offices have any stickers,
posters, pamphlets, or statements/questions about confidentiality health
questionnaires. The next barrier is the issue of privacy and confidentiality. While
75% reported that they always ask guardians to leave during the social history
and always discuss confidentiality with patients, that means that 25% are failing
to create a supportive environment.
The next set of barriers involves language. A majority (75%) of responding
pediatricians believed that they used language that was neutral and did not
presume sexual orientation or gender identity. This suggests that the remaining
pediatricians are using presumptive language that may dissuade the adolescent
from discussing such issues. While using gender-neutral language helps
establish trust, the next barrier is actually asking the question about sexual
orientation. Although nearly 90% of pediatricians always ask about sexual
activity, this does not identify many adolescents who are questioning or
identifying as GLBT. Of note, the age at which most adolescents were asked
about sexual activity was 13 years, but this age was older (14-16 years) in nonurban, mostly white and private insurance pediatric practices. Almost half (49%)
of pediatricians are asking about sexual orientation. While this does represent
an improvement from 10 years ago, when only 32% included sexual orientation
in the social history (2), it still indicates that many pediatricians are not asking
about the important issues of sexual attraction and perception of gender
identity. Practice characteristics also played a significant role in the age at which
pediatricians are asking patients if they are questioning or identifying as GLBT.
Practices that were “mostly white,” asked about sexual orientation at an older
age (14-16 years). This suggests that pediatricians in practices with primarily
suburban, white, privately insured patients assume that adolescents in their
practices engage in romantic relationships at an older age than their
counterparts.
The reasons why pediatricians are not asking about sexual orientation and
gender identity seem to focus on reservations about how to ask about such
sensitive issues. Again, there has been improvement since 1998 when 90%
expressed reservations (2). This study found 31% had reservations about
discussing such issues with patients. However, only 31% of pediatricians had
developed a specific phrase that they used to ask adolescents if they were
questioning or identifying GLBT. Not having a phrase or being able to find the
right words is not a new problem. Now, just as ten years ago, the most common
reason for reservations was “I don’t know how to ask the question.”
It appears that pediatricians now feel more knowledgeable and aware of
this population and its specific health needs. Ten years ago, 33% listed a lack of
knowledge as their major reservation for discussing GLBT issues with patients,
while today, 21% described a lack of knowledge as the major reservation (2).
Also, ten years ago 75% wanted and needed more information about GLBT
health, while only 41% requested additional information this year. GLBT issues
Special Issues Final Report, June 2008. Michelle Aubin, all rights reserved

 have received increasing visibility and advocacy and this may have resulted in
increased pediatrician awareness. It may be that pediatricians are more
knowledgeable and therefore feel less of a need for information.
This study indicates that pediatricians are taking steps towards creating a
private and confidential environment to discuss GLBT issues but are failing to
provide visual cues to their openness to discussing the issue and are failing to
initiate the conversation. Further research is needed to assess pediatrician
practice in a larger and more representative population. This should be
accompanied by research on adolescent views of how many of these practices
are actually reaching them. This preliminary study suggests that there is still
room for improvement in the identification of gay, lesbian, bisexual, and
transgender adolescents.
Acknowledgements:
The author would like to thank Professor Judy Lewis, Robin McHaelen and True
Colors for their support of this project.
References:
1. Allen LB, Glicken AD, Beach RK, Naylor KE. Adolescent health Care
Experience of Gay, lesbian, and Bisexual Young Adults. Journal of
Adolescent Health. 1998; 23: 212-220.
2. East JA, EL Rayess F. Pediatricians’ Approach to the Health Care of Lesbian,
Gay, and Bisexual Youth. Journal of Adolescent Health. 1998; 23: 191192.
3. Saewyc EM, Bearinger LH, Heinz PA, Blum RW, Resnick MD. Gender
Differences in Health and Risk Behaviors Among Bisexual and Homosexual
Adolescents. Journal of Adolescent Health. 1998; 23: 181-188.

Special Issues Final Report, June 2008. Michelle Aubin, all rights reserved

 Table 1: Pediatrician Demographics
Female
60%
Male
40%
0-7 yrs in practice
21%
8-25 yrs in practice
46%
>25 yrs in practice
33%
Non-Urban practice
51%
Urban practice (suburban/urban)
49%
Mostly white patients
57%
Mostly non-white patients
43%
Mostly private insurance
43%
Mostly non-private insurance (public/self57%
pay)

Table 2: Age Upon Which the Pediatrician First Asks About Sexual
Activity
Demographic
% Asking at ages
% Asking at P value
11-13 yrs
ages 14-16 yrs
Non-Urban practice 54%
46%
P = 0.014
Urban practice
81%
19%
Mostly white patients 56%
Mostly non-white patients
81%
Mostly private insurance
53%

44%
19%
43%

Mostly non-private insurance
78%

22%

P = 0.021
P = 0.022

Table 3: Age Upon Which the Pediatrician First Asks About
Sexual Orientation/Gender Identity
Insurance Type% Asking at ages
% Asking at ages P value
11-13 yrs
14-16 yrs
Mostly private 38%
62%
p = 0.029
Mostly non-private
75%
25%

Special Issues Final Report, June 2008. Michelle Aubin, all rights reserved