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• W2999800466 abstract "See Related Article on p.255Many sexual minority youth are at higher risk for poor health outcomes because of stigma, shame, and discrimination they may face because of their identity [[1]Ginsburg K.R. Kinsman S.B. American Academy of PediatricsGinsburg K.R. Kinsman S.B. Reaching teens : Strength-based communication strategies to build resilience and support healthy adolescent development. American Academy of Pediatrics, 2019Google Scholar]. Professional guidelines, including the American Academy of Pediatrics' Bright Futures, encourage discussion of sexual attraction and behavior in adolescent health supervision visits so that clinicians can support healthy adolescent sexual development, assure that the health needs of youth of all sexual identities are met, and facilitate family acceptance and support of youth when needed [[2]Adolescence visits: 11 through 21 years.in: Hagan J. Shaw J. Duncan P. Bright futures-guidelines for health supervision of infants, children, and adolescents. 4th ed. American Academy of Pediatrics, 2017: 731-822Google Scholar]. Although these discussions have been recommended as best practice for many years, we know that pediatricians generally spend little time addressing sexual health. In one study of audio-recorded pediatric well visits, one-third spent no time discussing sexuality or sexual health, and the average amount of time spent was only 36 seconds [[3]Alexander S.C. Fortenberry J.D. Pollak K.I. et al.Sexuality talk during adolescent health maintenance visits.JAMA Pediatr. 2014; 168: 163-169Crossref PubMed Scopus (130) Google Scholar]. To address this gap between recommendations and practice, some pediatric providers are incorporating questions about sexuality into electronic or other previsit screening tools [[4]Richardson L.P. Zhou C. Gersh E. et al.Effect of electronic screening with personalized feedback on adolescent health risk behaviors in a primary care setting: A randomized clinical trial.JAMA Netw Open. 2019; 2: e193581Crossref Scopus (14) Google Scholar]. In this issue of the Journal of Adolescent Health, Parmar et al. [[5]Parmar D.D. Alabaster A. Vance Jr., S. et al.Identification of sexual minority youth in pediatric primary care settings within a large integrated healthcare system using electronic health records.J Adolesc Health. 2020; 66: 255-257Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar] are the first to report findings from a large-scale implementation of a standardized assessment of sexual attraction at adolescent health supervision visits. See Related Article on p.255 In their report, Parmar et al. describe results derived from a standardized confidential written questionnaire administered to all adolescents aged 12.5–18 years, representing more than 107,000 respondents, and integrated into the electronic health record for health supervision visits across a large multi-site health care network in the U. S. The questionnaire asked youth a single item, whether they were attracted to “guys, girls, both, neither, or unsure,” and those who reported attraction to the same sex or both sexes were coded as sexual minority youth. The results demonstrated high response rates, with 87% of youth answering the question of sexual attraction, suggesting that this approach is feasible in a pediatric/adolescent primary care setting. Furthermore, 5% of youth reported same-sex or both-sex attraction, which is similar to rates observed in population-based studies of youth, such as the Centers for Disease Control and Prevention Youth Risk Behavior Survey [6Kann L. McManus T. Harris W.A. et al.Youth risk behavior surveillance - United States, 2017.MMWR Surveill Summ. 2018; 67: 1-114Crossref PubMed Google Scholar, 7Kann L. Olsen E.O.M. McManus T. et al.Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9-12 - United States and selected sites, 2015.MMWR Surveill Summ. 2016; 65: 1-202Crossref Scopus (898) Google Scholar, 8Luk J.W. Gilman S.E. Haynie D.L. Simons-Morton B.G. Sexual orientation differences in adolescent health care access and health-promoting physician advice.J Adolesc Health. 2017; 61: 555-561Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar]. It is encouraging that observed rates of same- and both-sex sexual attraction are similar across these settings, suggesting that many youth felt safe enough to share this important information in a clinical setting with their medical provider. As the authors note, this type of screening represents a critical first step in addressing the health care needs of sexual minority youth, as it may signal clinician openness to discussing sexual development and acceptance of a range of sexual attractions, and also aids in identifying sexual minority youth. Nonetheless, it is important to highlight the limitations of a single-question approach, and that further information will need to be collected. A single item regarding sexual attraction is not sufficient to determine an adolescent's sexual identity (e.g., lesbian, gay, bisexual, straight, etc.) or their actual sexual behavior, which may or may not align with their sexual attraction. One may argue that understanding a youth's sexual identity or actual sexual behavior may be of even greater clinical importance, as this information could help to facilitate discussion about coming out or targeted STI/HIV testing and risk-reduction counseling. Clinicians will still need to ask about sexual behavior in a way that recognizes the nuances and variability in gender identity and sexual attractions. Knowing the gender to which a youth is attracted or even the gender of their sexual partner(s) does not explain the type of sexual contact they are having. Adolescent responses to screening questions will need to be followed by face-to-face discussions with clinicians. Prior research suggests that many providers lack comfort and knowledge in caring for sexual and gender minority individuals [[9]Knight R.E. Shoveller J.A. Carson A.M. Contreras-Whitney J.G. Examining clinicians' experiences providing sexual health services for LGBTQ youth: Considering social and structural determinants of health in clinical practice.Health Educ Res. 2014; 29: 662-670Crossref PubMed Scopus (48) Google Scholar,[10]Honigberg M.C. Eshel N. Luskin M.R. et al.Curricular time, patient exposure, and comfort caring for lesbian, gay, bisexual, and transgender patients among recent medical graduates.LGBT Health. 2017; 4: 237-239Crossref PubMed Scopus (18) Google Scholar]. Although eliciting information on sexual attraction is a necessary step toward the improvement of care, simply eliciting this information without adequate provider knowledge and skill could at times have the inadvertent effect of facilitating further stereotyping, marginalization, or unwanted disclosure of sexual minority youth. Despite these limitations and concerns, completion of previsit questionnaires by adolescents has previously been found to be positively associated with the discussion of potentially sensitive health topics with a provider and could have many benefits [[4]Richardson L.P. Zhou C. Gersh E. et al.Effect of electronic screening with personalized feedback on adolescent health risk behaviors in a primary care setting: A randomized clinical trial.JAMA Netw Open. 2019; 2: e193581Crossref Scopus (14) Google Scholar,[11]Santelli J.S. Klein J.D. Song X. et al.Discussion of potentially sensitive topics with young people.Pediatrics. 2019; 143https://doi.org/10.1542/peds.2018-1403Crossref Scopus (29) Google Scholar]. Implementation of previsit screening pertaining to sexuality and sexual activity will need to be complemented by other efforts to achieve the greatest benefit. For example, there is a critical need for further provider training on conducting comprehensive sexual histories, providing appropriate testing and counseling, discussing sexual identity, and appropriately referring sexual minority youth for support when needed—none of which can be substituted by electronic screening alone. In addition to these and other benefits mentioned by Parmar et al., we also believe that this type of previsit screening may benefit all adolescents, not just those who identify as sexual minorities. Asking questions about the range of sexual attraction in the pediatric/adolescent primary care setting normalizes sexual identity across the spectrum, decreases stigma, and helps signal to youth that this is a safe space to discuss questions and concerns about sexuality [[1]Ginsburg K.R. Kinsman S.B. American Academy of PediatricsGinsburg K.R. Kinsman S.B. Reaching teens : Strength-based communication strategies to build resilience and support healthy adolescent development. American Academy of Pediatrics, 2019Google Scholar]. It is also important to ask these questions periodically within a developmental context as adolescents' sexual identities evolve over time. Parmar et al. should be applauded for this first critical step in demonstrating successful screening for sexual attraction in a diverse population of youth in the pediatric primary care setting, yet several questions remain for future research and implementation. How will we ensure that responses to these types of previsit screening questionnaires are confidentially integrated into the electronic health record and with the appropriate decision support for busy primary care providers? Can we demonstrate measurable physical and mental health benefits of this type of screening for sexual minority youth on a broad scale? Will extending previsit screening to include questions about gender identity, which is also recommended by Bright Futures [[12]American Academy of PediatricsMiddle adolescence: 15 through 17 year visits.in: Hagan J. Shaw J. Duncan P. Bright futures-guidelines for health supervision of infants, children, and adolescents. 4th ed. American Academy of Pediatrics, 2017: 767-797Google Scholar], help to address the health needs of transgender and gender-diverse youth? We look forward to Parmar et al.'s reporting on this item, which is currently under study. Guss et al. [[13]Guss C.E. Khan A. Gordon A.R. 196. “It'd be great to have the options there”: Adolescent impressions of gender identity collection on forms in a primary care clinic.J Adolesc Health. 2019; 64: S100Abstract Full Text Full Text PDF Google Scholar] have previously shown that questions on preferred name, preferred pronouns, sex assigned at birth, and gender identity in a written previsit questionnaire were understandable and acceptable to adolescents. Ultimately, in this new era of electronic previsit screening, there will be many opportunities and challenges to improving sexual, gender, and reproductive health for all youth, including marginalized populations of sexual minority youth. However, one thing remains certain—whether communication is face-to-face, with paper, or with electronic tools—to address these key aspects of health in the primary care setting, we must first ask the questions. Identification of Sexual Minority Youth in Pediatric Primary Care Settings Within a Large Integrated Healthcare System Using Electronic Health RecordsJournal of Adolescent HealthVol. 66Issue 2PreviewThe aim of the study was to estimate the prevalence of sexual minority youth (SMY) within an integrated health care system using a standardized questionnaire. Full-Text PDF" @default.
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• W2999800466 title "Opportunities and Challenges for Previsit Screening for Sexual and Gender Identity Among Adolescents in Primary Care" @default.
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