Community Voices Series

The Reproductive Health Conundrum in working with Lesbian and Gay Teens

David A. Levine, MD, Professor of Pediatrics, Morehouse School of Medicine

Multiple studies with samples drawn from various nations find that lesbian and gay identified youth ages 14-19 have pregnancy rates two to seven times greater than their heterosexual peers. Additionally, their pregnancy rates continue to rise, even though the overall teen pregnancy rate is declining in the United States.

This will surprise a lot of experts and certainly shock the community.  After all, if they say that they are lesbian or gay, doesn’t that mean that they have sex with their own gender?  That of course, cannot lead to pregnancy.  The reality check is that many, if not virtually all, lesbian or gay teens have had sex with the opposite gender as well.  And in those situations, there is not a common use of birth control.   Providers that work with lesbian and gay adolescents will recognize that sexual identity does not always match sexual behavior.  As one lesbian teen was quoted in a frequently used training presentation, “it is easier to find male partners for sex at my high school and so I continue to have sex with both genders.”

Let’s add the concept of intersectionality.  The Merrion-Webster dictionary defines the concept as the “complex, cumulative way in which the effects of multiple forms of discrimination (such as racism, sexism, and classism) combine, overlap, or intersect especially in the experiences of marginalized individuals or groups.”  I like to think of people as having a 4th dimension – the dimension of behavior.  Each individual will react differently based upon their unique story.  And behavior is often not predictable.  Sexual behavior can be even more unpredictable

So how do we work best with lesbian and gay teens to try to reduce teen pregnancy for these vulnerable youth?  Our first step needs to be advocacy.  Advocacy for equal access, equal rights, and equal education.  Many school districts are teaching abstinence only until heterosexual marriage curricula.  That is the quickest way to get our lesbian and gay students to “zone out” since the program doesn’t involve them or even allow that they have a right to have education on healthy sexuality.  We need to continue to fight for comprehensive sexuality education that provides frank, appropriate, and useful information for all of our young people.

Our next step is to work with the individual. We should never assume that the clients are having sex that is congruent with their self-identified sexual orientations.  We should ask, not assume.  If the teen has not yet self-identified as gay or lesbian, we should always use gender neutral questions.  “Are you dating or seeing anyone?”  “Are you in a relationship?” “Tell me about your sexual partner.”  Eventually we need to get to the discrete question, “Are you having sex?”  If yes, “Are you having sex with men, women, both, neither?”  If the patient never has had sex we should ask, “When you think of future sexual partners, are they men, women, both, neither?”  For those that have been open and frank with you and have identified their sexual orientation to you, a normalizing statement can be offered.  “Thanks so much for trusting me with this information.  Though I know you just told me that you were gay, sometimes young people may have sex that is not predicted by the orientation.  Have had sex with men, women, both, neither?

Occasionally, a straight teen might respond, “I’m not gay!”  Our response should be that we ask that question of everyone.  Rarely a lesbian or gay teen might say “I only have sex with ….”  A similarly normalizing statement would be warranted.

And of course, if we discover sexual behavior, we need to obtain a comprehensive sexual history.  The CDC’s 5 Ps are a good place to start – Partners (including gender), Practices (vaginal, oral, anal intercourse, or other sexual practices), Protection from STDs, Past History of STDs, Prevention of Pregnancy.  A frank discussion of risk should ensue.  The teen may decide that she would like to use a method immediately and we can start any method quickly.  Others will be undecided and should be scheduled to return at a short interval time to continue the discussion.  ALL sexually active teens with female anatomy should at very least leave with an advanced prescription for emergency contraception.  While not as effective as regular birth control, this is a safe alternative for some teens.  Offering the best contraception should be offered – especially the IUD or implant (so called long acting reversible contraceptives – LARCs) to all teens with female anatomy.

Done in a sensitive way, acknowledging the teen as a sentient person capable of making health decisions, frank discussions, and comprehensive sexuality education are the solutions that we know will be effective.  We cannot stereotype our teens based on societal expectations of their sexual orientation.  Providing the enhanced services, using cultural humility, is the way that we can reduce the health disparity and achieve our goal of health equity for all adolescents.  Gay and lesbian parents are fine parents; but like everyone else, children that are planned for have better outcomes.  Let’s help our lesbian and gay teens navigate adolescence and young adulthood in a positive way, with a good image of sexuality, free of additional risks.