Dr Jessica Salkind, Dr Rosanna Bevan and Dr Gayle Hann
Pansexual, polysexual, biromantic, agender, genderqueer… These are just a handful of the terms that people who fit under the LGBT+ umbrella may use to describe themselves. The acronym itself is not fixed – you might have seen LGBT+ (lesbian, gay, bisexual, transgender with the + denoting that this is an inclusive group), LGBTQ (Q = queer or questioning) or LGBTQIA (I = intersex, A = asexual). What may initially appear to be a minefield of new terminology and political correctness can be simplified with a basic understanding of the experiences of this community and some tips for making paediatric services more inclusive. It’s much more about listening and respect than about a complex new vocabulary.
Sexual orientation – what do you need to know?
In the 2017 UK Office of National Statistics (ONS) data, 4.1% of those aged 16-24 classified themselves as lesbian, gay or bisexual (LGB). In a Yougov poll from 2015, only 46% of 18-24 year olds classed themselves as ‘exclusively heterosexual’ – in other words, more than half saw themselves as somewhere else along this spectrum. This clearly isn’t measuring active bisexuality but it reflects an increasing understanding of sexuality as a spectrum. Many young people don’t give themselves a label: some find it limiting and unhelpful; others are still figuring things out. We can fall into the trap of giving a young person a label they have not given themselves: a young man who is attracted to, or has sex with men is not ‘gay’ unless he tells you that he is. Another key thing to remember is that sexual orientation does not dictate behaviour. A person who is asexual (i.e. who does not experience sexual attraction to anyone) may still have sex for many different reasons – this is important in terms of risk assessment and sexual health.
Image 1: Yougov survey, 2015 – sexual orientation of adults in Great Britain
Sex and gender
Sex is biological: it’s the complex combination of karyotype/genetics, external genitals, gonads, secondary sex characteristics and hormones. Most people are assigned the sex ‘male’ or ‘female’ at birth, on the basis of a midwife or paediatrician having a look at what’s between their legs. Gender describes how we identify – as a man, woman, both, neither or something else altogether. Cisgender (cis) people have a gender identity which consistently matches the sex they were assigned at birth; transgender (trans) people do not. Some trans people have binary identities – a trans woman is a woman who was assigned ‘male’ at birth. Non-binary people have an identity which is neither exclusively ‘man’ or ‘woman’ (it’s outside of this binary). Non-binary people may use pronouns other than ‘he’ or ‘she’ e.g. ‘they’ as a singular (“Sam used their inhaler”), ‘xe’ or ‘per’.
All of this might sound very complicated but it’s actually simple: a person’s gender is whatever they tell you it is. Call them by the name and pronouns that they want you to use. Unlike for sexual orientation, the UK Office of National Statistics does not collect information on gender identity but estimates of the transgender population are in the region of 1% of the population as a whole – some European studies have found it to be higher than this.
Gender dysphoria and the GIDS
In recent years, there has been a lot of inaccurate media reporting about the experiences and care of transgender and gender non-conforming children and young people. In particular, headlines about genital surgery for children – this simply does not happen. Gender dysphoria describes the discomfort or distress that a person can feel where there is a mismatch between their gender and their biological sex. For under 18s in the UK, the appropriate place to refer to is the Gender Identity Development Service at the Tavistock and Portman. Paediatricians can refer, as can child and adolescent mental health services (CAMHS), GPs, social care and schools but patients and their families cannot self refer.
Referrals have increased significantly in recent years and there may be several months to wait for the first appointment. Care in the GIDS is holistic with psychological assessment and support for young people and their families. They work closely with Paediatric Endocrinologists who, where appropriate, can prescribe gonadotropin releasing hormone analogues (hormone ‘blockers’) to young people with gender dysphoria from tanner stage 2 of puberty – these are safe and reversible, and have been used for many years in children with precocious puberty without adverse effects. Cross sex hormones (oestrogen and testosterone) are available from age 16 onwards, under certain, strict criteria. In the NHS, surgery is only ever within adult services for over 18s.
What are the problems faced by this community?
In many ways, in many parts of the world, life is easier than it ever has been for LGBT+ people. Legal equality and social progress go hand in hand – you may well encounter LGBT+ young people who are proud of this aspect of their identity and face no specific issues. With that in mind, it is important to be aware of the ongoing inequalities in this community, in particular the higher rates of mental health problems and of safeguarding risks. A recent Stonewall survey of 3713 LGBT+ UK school children, found 61% of LGB and 84% of trans young people had self harmed, and 22% of LGB and 45% of trans young people had made a suicide attempt. These higher rates have been linked to social inequality. ‘Coming out’ to family may result in rejection – up to 1/4 homeless young people in the UK are thought to be LGBT+ (Albert Kennedy Trust, 2015), and there are other risks such as being sent to ‘conversion therapy’ which can be hugely damaging and has been widely condemned. Stonewall found 45% of LGBT+ pupils have been bullied due to their sexual orientation or gender identity. These problems can be compounded by negative media attitudes and the risk of violent hate crime.
How does this impact my practice?
The most important thing you can do is to represent a non-judgemental adult who can be trusted. Sadly, the evidence is that LGBT+ patients do not always have positive experiences when accessing the NHS. We recommend using LGBT+ inclusive language with every patient you meet, and not stereotyping about who is likely to be LGBT+. In terms of sexual orientation, avoid heterosexist language which assumes everyone is straight (the classic example of this is asking a teenage girl “do you have a boyfriend?”) and reflect the language used by the young person in front of you. If you encounter a trans or non-binary young person, respect the name and pronouns they use (even if their parents do not) and update the rest of the team/medical records as appropriate. For many LGBT+ young people, these simple acts of respect are sufficient, but where you identify risks as described above, involve your local child protection team, CAMHS and social care as appropriate. It can be helpful to make your ward visibly LGBT+ friendly with posters and it can be useful to have details of local LGBT+ organisations available.
Do you know how to react if a young person comes out to you as LGB or trans?
This your opportunity to be a safe adult they can trust so it’s really important to:
- Acknowledge what they have told you! Don’t show how cool you are with it by moving on immediately – it is possible you are the first person they have ever told.
- Mirror their language – only use a label that they have given themselves (a teenage boy with a boyfriend is not ‘gay’ unless he tells you he is)
- Reassure them about confidentiality
- Help guide them to relevant services – where relevant, refer to the GIDS
Things it is better not to do:
- Give your personal opinion (even if it’s a positive one)
- Be accidentally patronising (“good for you!”)
- Pressure them to come out to others before they are ready – remember coming out can be a dangerous process for some LGBT+ young people
- Ask irrelevant questions which may be perceived as intrusive
Key learning points
Respect the language used by the patient – everyone has the right to define their own identity
You cannot tell who is LGBT+ by looking at them – challenge any stereotypes you might hold and use inclusive language for every patient
Remember that this is a group at higher risk of mental health problems and safeguarding risks – do a full HEEADSSS assessment and involve your seniors and appropriate agencies as needed
Stonewall: UK’s biggest LGBT+ rights charity
Albert Kennedy Trust: a charity working with homeless LGBT+ young people
Gendered Intelligence: organisation for trans/non-binary young people
Mermaids UK: family and individual support for trans and gender diverse children and young people
CliniQ: sexual health and wellbeing services for trans people