IN THE CIRCUIT COURT FOR MONTGOMERY COUNTY, MARYLAND
Civil Action No. 284980V
PETITION OF CITIZENS FOR A RESPONSIBLE CURRICULUM, et al.
FOR JUDICIAL REVIEW OF THE DECISION OF THE MARYLAND STATE BOARD OF EDUCATION
IN THE CASE OF
CITIZENS FOR A RESPONSIBLE CURRICULUM, et al. v . MONTGOMERY COUNTY PUBLIC SCHOOLS, et al. )
RESPONDENT PFLAG'S STATEMENT IN LIEU OF MEMORANDUM
As provided for by Maryland Rule 7-207(a), Respondent Parents, Families, and Friends of Lesbians and Gays of Metropolitan Washington, D.C. ("PFLAG") adopts by reference the Memorandum in Response to the Petition for Review filed by Respondents Montgomery County Board of Education, Montgomery County Public Schools, and Jerry D. Weast (collectively, "the MCPS Respondents"). The State Board of Education's decision should be upheld for the reasons stated in the MCPS Respondents' Memorandum. PFLAG files separately to call the Court's attention to additional record material filed in the administrative proceeding under review. See Exhibit 1 (Letter to the Maryland State Board of Education, dated March 29, 2007).
In the proceeding below, PFLAG submitted policy statements and clinical guidance from the American Academy of Pediatrics, the American Psychological Association, and the American Medical Association calling upon educators to provide support for students regardless of their sexual orientation, id., Attach. A at 1831, Attach. B at 3; concluding that homosexuality is not a disorder, id., Attach. A at 1828, Attach. B at 2; and indicating the potential harm posed by attempts to modify sexual orientation, id., Attach. C. The Revised Lessons, as adopted, are fully in accord with the positions of these leading medical and counseling organizations. Petitioners therefore have no basis for asserting that "a reasoning mind could not have reasonably reached the conclusion" to teach such material. Pet'r. Mem. at 5.
The issue before the Court, however, is not whether the conclusions of the leading medical and counseling organizations are correct, despite the Petitioners' attempt to draw the Court into such a debate. Rather, the only question on review is whether the State Board of Education erred in permitting the MCPS Respondents to implement a curriculum whose content is consistent with these organizations' clinical and policy guidance. The MCPS Respondents' Memorandum explains in detail why the State Board's decision should stand. Simply put, Maryland law entrusts the State Board of Education and the county boards with the discretion and authority to promulgate a health curriculum, and it would be impossible for them to exercise their intended role if every person who disagreed with the inclusion or phrasing of a lesson could use the courts to blue- pencil the particular words or ideas she didn't like.
Dated: November 28, 2007
Respectfully submitted,
Daniel H. Squire
Jonathan J. Frankel
Ryan P. Phair (admitted to the State of Maryland Bar)
Kenny A. Wright
Daniel J. Matheson
Brian M. Simmonds
Wilmer Cutler Pickering Hale and Dorr LLP
1875 Pennsylvania Avenue, NW
Washington, DC 20006
(202) 663-6000 (t)
(202) 663-6363 (f)
Hayley Gorenberg
Lambda Legal
120 Wall Street, Suite 1500
New York, NY 10005
(212) 809-8585 (t)
(212) 809-0055 (f)
Attorneys for Respondent,
Parents, Families and Friends of
Lesbians and Gays of Metropolitan Washington, D.C.
*********************************
John R. Garza
Garza, Regan & Associates
17 West Jefferson Street Rockville, Maryland 20850
Brandon Bolling
Thomas More Law Center
24 Frank Lloyd Wright Drive
P.O. Box 393
Ann Arbor, Michigan 48105
Judith S. Bresler
Reese & Carney, LLP
Hawthorn Executive Center
10715 Charter Drive Columbia, MD 21044-2868
Nancy S. Grasmick
Maryland State Department of
Education
200 West Baltimore Street
Baltimore, Maryland 21201-2595
Edward L. Root
Maryland State Board of Education
200 West Baltimore Street
Baltimore, Maryland 21201-2595
Jackie Lasiandra
Office of the Attorney General
200 St. Paul Place, 19th Floor
Baltimore, Maryland 21202
Brian M. Simmonds
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EXHIBIT 1
March 29, 2007
Via E-Mail and First Class Mail
Maryland State Board of Education
200 West Baltimore Street Baltimore, Maryland 21201
RE: Citizens for a Responsible Curriculum et al. v. Montgomery County Board of Education
Dear Members of the Maryland State Board of Education:
I write this letter as a member of the Board of Directors of the Metro DC Chapter of Parents, Families, and Friends of Lesbians and Gays (PFLAG). We were pleased that Superintendent Grasmick denied petitioners' request to halt the field-testing of the Montgomery County Public Schools (MCPS) health education curriculum revisions.
In light of Dr. Grasmick's opinion, we would like to provide some additional perspective on the matter as you consider the petition.
Here, MCPS has chosen to discuss sexual orientation in 8th and 10th Grade Health Education classes. The curriculum revisions are Important for the well-being of students and reflect the viewpoints of every mainstream medical and mental health professional association. It is certainly proper for any school system to base its health curriculum on information from, and conclusions of, mainstream medical and mental health professional associations. Indeed, MCPS relied upon experts presented by the Maryland Chapter of the American Academy of Pediatrics (AAP) in developing and reviewing its curriculum materials.
While the revisions being field-tested do not include everything the AAP says on the subject of sexual orientation, we believe it useful for the State Board of Education to know that the AAP, in its Guidance for the Clinician on Sexual Orientation and Adolescents (published in PEDIATRICS, Vol. 113, No. 6 (June 2004) (Attachment A, available at http://pediatrics.aappublications.org/cgi/content/full/113/6/1827)), notes with approval the fact that in "1973, the American Psychiatric Association reclassified homosexuality as a sexual orientation or expression and not a mental disorder" (p. 1828). In this same Guidance, the AAP goes on to note that "the current literature and most scholars in the field state that one's sexual orientation is not a choice; that is, individuals do not choose to be homosexual or heterosexual. " Id. Moreover, the AAP (a) encourages its members to " [b]e supportive of parents of adolescents who have disclosed that they are not heterosexual, (b) informs its members that " [m]ost states have chapters of Parents and Friends of Lesbians and Gays (PFLAG) to which interested families may be referred, " and (c) encourages its members to " [r]emind parents and adolescents that gay and lesbian individuals can be successful parents themselves." Id at 1830-31.
Similarly, the American Psychological Association (which is also quoted in the MCPS curriculum revisions), in its on-line publication Answers to Your Questions About Sexual Orientation and Homosexuality (Attachment B, available at http://www.apa.org/topics/orientation.html), states that sexual orientation is not a "conscious choice that can be voluntarily changed; " that homosexuals can "live successful, happy lives; " that "homosexuality is not an illness, it does not require treatment and is not changeable; "that both the American Psychiatric Association and the American Psychological Association urge "all mental health professionals to dispel the stigma of mental illness that some people still associate with homosexual orientation;" and that "[s]tudies comparing groups of children raised by homosexual and heterosexual parents find no developmental differences between the two groups of children .... [and] that a parent's sexual orientation does not dictate his or her children's [sexual orientation]."
Finally, we note that while a principal gravaman of petitioners' appeal is their assertion that the so-called "ex-gay" viewpoint - that homosexuality is a disorder that can and should be cured - should be included in the health curriculum, this approach is directly contrary to the official position of the American Medical Association, which "opposes the use of `reparative' or `conversion' therapy that is based upon the assumption that homosexuality per se is a mental disorder or based upon the a priori assumption that the patient should change his/her homosexual orientation. " AMA Policy Number H- 160.9916 Health Care Needs of the Homosexual Population (Attachment C, available at at http://www.ama-assn.org/ama/pub/category/14754.html) . The AMA recognizes the dangers of the "ex-gay" approach. MCPS should not be forced to include in its health curriculum a "perspective" that has been rejected by the AMA.
In sum, MCPS has taken excellent first steps in dealing with the important issues covered by the revisions and has done so in close consultation with medical experts. For the Board's reference, we also attach, as Attachment D, a Fact Sheet summarizing the positions of the American Medical Association, the American Academy of Pediatrics, and the American Psychological Association.
Attachments
cc: John R. Garza, Counsel for Petitioners
Judith S. Bresler, Counsel for Montgomery County Board of Education
Jackie Lasiandra, Assistant Attorney General for State of Board of Education
Elizabeth Kameen, Assistant Attorney General for State of Board of Education
Sincerely,
David S. Fishback XXXXXXXXXXXXX, Olney, MD 20832
************************************************************************************
ATTACHMENT A
American Academy of Pediatrics
Guidance for the Clinician on Sexual Orientation and Adolescents
(published in PEDIATRICS, Vol. 113, No. 6 (June 2004)
http://pediatrics.aappublications.org/cgi/content/full/113/6/1827
AMERICAN ACADEMY OF PEDIATRICS
CLINICAL REPORT
Guidance for the Clinician in Rendering Pediatric Care
Barbara L. Frankowski, MD, MPH; and the Committee on Adolescence
Sexual Orientation and Adolescents
ABSTRACT: The American Academy of Pediatrics is-sued its first statement on homosexuality and adolescents in 1983, with a revision in 1993. This report reflects the growing understanding of youth of differing sexual orientations. Young people are recognizing their sexual orientation earlier than in the past, making this a topic of importance to pediatricians, Pediatricians should be aware that some youths in their care may have concerns about their sexual orientation or that of siblings, friends, parents, relatives, or others. Health care professionals should provide factual, current, nonjudgmental information in a confidential manner. All youths, including those who know or wonder whether they are not heterosexual, may seek information from physicians about sexual orientation, sexually transmitted diseases, substance abuse, or various psychosocial difficulties. The pediatrician should be attentive to various potential psychosocial difficulties, offer counseling or refer for counseling when necessary and ensure that every sexually active youth receives a thorough medical history, physical examination, immunizations, appropriate laboratory tests, and counseling about sexually transmitted diseases (including human immunodeficiency virus infection) and appropriate treatment if necessary.
Not all pediatricians may feel able to provide the type of care described in this report. Any pediatrician who is unable to care for and counsel nonheterosexual youth should refer these patients to an appropriate colleague. Pediatrics 2004;113:1827-1832; sexual orientation, adolescents, homosexuality, gay, lesbian, bisexual.
ABBREVIATIONS. STD, sexually transmitted disease; HIV, hu- man immunodeficiency virus; AAP, American Academy of Pediatrics; AIDS, acquired immunodeficiency syndrome.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Academy of Pediatrics.INTRODUCTION
Pediatricians are being asked with increasing frequency to address questions about sexual behavior and sexual orientation. It is important that pediatricians be able to discuss the range of sexual orientation with all adolescents and be competent in dealing with the needs of patients who are gay, lesbian, bisexual, or transgendered or who may not identify themselves as such but who are experiencing confusion with regard to their sexual orientation. Young people whose sexual orientation is not heterosexual can have risks to their physical, emotional, and social health, primarily because of societal stigma, which can result in isolation. 1'2 Because self- awareness of sexual orientation commonly occurs during adolescence, the pediatrician should be avail- able to youth who are struggling with sexual orientation issues and support a healthy passage through the special challenges of the adolescent years. Pediatricians may be called on to help parents, siblings, and extended families of nonheterosexual youth. Also, nonheterosexual youth and adults are part of peer groups with whom all pediatric patients and their parents spend time in the neighborhood, at school, or at work. Thus, pediatricians may be called on to help promote better understanding of issues involving nonheterosexual youth.
Gay, lesbian, and bisexual people in the United States have unique health risks. The US Department of Health and Human Services has identified 29 Healthy People 2010 objectives in which disparities exist between homosexual or bisexual persons and heterosexual persons. These focus areas include ac- cess to care, educational and community-based pro- grams, family planning, immunization and infectious disease, sexually transmitted diseases (STDs) including human immunodeficiency virus (HIV) infection in jury and violence prevention, mental health and mental disorders, substance abuse and tobacco use. 3
DEFINITIONS
Sexual orientation4,5 refers to an individual's pat- tern of physical and emotional arousal toward other persons. Heterosexual individuals are attracted to persons of the opposite sex, homosexual individuals are attracted to persons of the same sex, and bisexual individuals are attracted to persons of both sexes. Homosexual males are often referred to as "gay"; homosexual females are often referred to as "lesbian." In contrast, gender identity is the knowledge of oneself as being male or female, and gender role is the outward expression of maleness or femaleness. Gender identity and gender role usually conform to anatomic sex in both heterosexual and homosexual individuals. Exceptions to this are transgendered individuals and transvestites. Transgendered individuals feel themselves to be of a gender different from their biological sex; their gender identity does not match their anatomic or chromosomal sex. Transvestites are individuals who dress in the clothing of the opposite gender and derive pleasure from such actions; their gender role does not match societal norms. Transgendered individuals and transvestites can be heterosexual, homosexual, or bisexual.
Sexual orientation is not synonymous with sexual activity or sexual behavior (the way one chooses to express one's sexual feelings). Certain sexual behaviors can put individuals of any sexual orientation at risk of pregnancy (penile-vaginal sexual intercourse) and/or certain diseases (penile-vaginal, oral, and anal sexual intercourse). Especially during adolescence, individuals may participate in a variety of sexual behaviors. Many homosexual adults report having relationships and sexual activity with persons of the opposite sex as adolescents,6,7 and many adults who identify themselves as heterosexual re- port sexual activity with persons of the same sex during adolescence. 8-1o Also, any youth label themselves as gay, lesbian, or bisexual years after labeling their attractions as such. 11 In addition, adolescents may also self-identify as nonheterosexual without ever being sexually active. Pediatricians need to understand that they should inquire about sexual attraction or orientation even when youth do not report being gay or lesbian.
ETIOLOGY AND PREVALENCE
Homosexuality has existed in most societies for as long as recorded descriptions of sexual beliefs and practices have been available.4 Societal attitudes to- ward homosexuality have had a decisive effect on the extent to which individuals have hidden or made known their sexual orientation.
Human sexual orientation most likely exists as a continuum from solely heterosexual to solely homo- sexual. In 1973, the American Psychiatric Association reclassified homosexuality as a sexual orientation or expression and not a mental disorder. 12 The mechanisms for the development of a particular sexual orientation remain unclear, but the current literature and most scholars in the field state that one ' s sexual orientation is not a choice; that is, individuals do not choose to be homosexual or heterosexual. 8,11
A variety of theories about the influences on sexual orientation have been proposed. 5 Sexual orientation probably is not determined by any one factor but by a combination of genetic, hormonal, and environ- mental influences.2 In recent decades, biologically based theories have been favored by experts. The high concordance of homosexuality among monozygotic twins and the clustering of homosexuality in family pedigrees support biological models. There is some evidence that prenatal androgen exposure influences development of sexual orientation, but post- natal sex steroid concentrations do not vary with sexual orientation. The reported association in males between homosexual orientation and loci on the X chromosome remains to be replicated. Some research has shown neuroanatomic differences between homosexual and heterosexual persons in sexually dimorphic regions of the brain.5 Although there continues to be controversy and uncertainty as to the genesis of the variety of human sexual orientations, there is no scientific evidence that abnormal parent- ing, sexual abuse, or other adverse life events influence sexual orientation.4,5 Current knowledge suggests that sexual orientation is usually established during early childhood. 1,2,4,5
The estimated proportion of Americans who are homosexual is imprecise at best, because surveys are hampered by the stigmatization and the climate of fear that still surround homosexuality. Past studies asked more often about sexual behavior and not sexual orientation. Kinsey et al9,13 from their studies in the 1930s and 1940s, reported that 37% of adult men and 13% of adult women had at least 1 sexual experience resulting in orgasm with a person of the same sex and that 4% of adult men and 2% of adult women are exclusively homosexual in their behavior and fantasies. A more recent review of various US studies estimated that 2% of men are exclusively homosexual and 3OL are bisexual. 14 Other current studies conclude that somewhere between 3% and 10% of the adult population is gay or lesbian, and perhaps a larger percentage is bisexual. 4,5 Sorenson l5 surveyed a group of 16- to 19-year-olds and reported that 6% of females and 17% of males had at least 1sexual experience with a person of the same sex. Remafedi et al, 10 in a large, population-based study of junior and senior high school students performed in the late 1980s that measured sexual fantasy, emotional attraction, and sexual behavior, found that more than 25% of 12-year-old students felt uncertain about their sexual orientation. This uncertainty de- creased with the passage of time and increasing sexual experience to only 5% of 18-year-old students. Only 1.1% of students reported themselves as pre- dominantly homosexual or bisexual. However, 4.5% reported primary sexual attractions to persons of the same sex, which better reflects actual sexual orientation. The Garofalo et al study, 16 based on the 1995 Massachusetts Youth Risk Behavior Survey, found that 2.5% of youth self-identified as gay, lesbian, or bisexual.
These data illustrate the complexity of labeling sexual orientation in adolescents. Health care professionals should be aware that a large number of adolescents have questions about their sexual feelings; some are attracted to and may have sexual relations with people of the same sex, and a small number may know themselves to be gay or lesbian.
SPECIAL NEEDS OF NONHETEROSEXUAL AND QUESTIONING YOUTH
The overall goal in caring for youth who are or think they might be gay, lesbian, or bisexual is the same as for all youth: to promote normal adolescent development, social and emotional well-being, and physical health. If their environment is critical of their emerging sexual orientation, these adolescents may experience profound isolation and fear of discovery, which interferes with achieving developmental tasks of adolescence related to self-esteem, identity, and intimacy. 17,18 Nonheterosexual youth often are subjected to harassment and violence; 45% of gay men and 20% of lesbians surveyed were victims of verbal and physical assaults in secondary school specifically because of their sexual orientation. 1,19
Nonheterosexual youth are at higher risk of drop- ping out of school, being kicked out of their homes, and turning to life on the streets for survival. Some of these youth engage in substance use, and they are more likely than heterosexual peers to start using tobacco, alcohol, and illegal drugs at an earlier age. 2° Nonheterosexual youth are more likely to have had sexual intercourse, to have had more partners, and to have experienced sexual intercourse against their will,20 putting them at increased risk of STDs includ- ing HIV infection. In a recent study of HIV seroprevalence, 7% of 3492 15- to 22-year-old males who have sex with males living in 7 US cities were HIV- seropositive. Among adolescent males who have sex with males, HIV seroprevalence rates in descending order were highest among black adolescents, then "mixed race or other " adolescents, and then Hispanic adolescents and were lowest among Asian and white adolescents.21 Women having sex with women have the lowest risk of any STD, but lesbian adolescents remain at significant risk because they are likely to have had sexual intercourse with males. Youth in high school who identify themselves as gay, lesbian, or bisexual; engage in sexual activity with persons of the same sex; or report same-sex romantic attractions or relationships are more likely to attempt suicide, be victimized, and abuse substances. 20,22 Although only representing a portion of youth who someday will self-identify as gay, lesbian, or bisexual, school-based studies have found that these adolescents, compared with heterosexual peers, are 2 to 7 times more likely to attempt suicide, 16,19,23,24 are 2 to 4 times more likely to be threatened with a weapon at school, 16,23 and are more likely to engage in frequent and heavy use of alcohol, marijuana, and cocaine. It is important to note that these psychosocial problems and suicide attempts in nonheterosexual youth are neither universal nor attributable to homosexuality per se, but they are significantly associated with stigmatization of gender nonconformity, stress, violence, lack of support, dropping out of school, family problems, acquaintances' suicide attempts, homelessness, and substance abuse.2,25 In addition to suicidality, young gay and bisexual men might also suffer body image dissatisfaction and disordered eating behaviors for some of the same reasons.26
Nonheterosexual youth are represented within all populations of adolescents, all social classes, and all racial and ethnic groups. Ethnic minority youth who are nonheterosexual are required to manage more than one stigmatized identity, which increases their level of vulnerability and stress. 27 They retain their minority status when they seek help in the predominately white gay and lesbian support communities. In addition, sexual minority youth are represented among handicapped adolescents, homeless adolescents, and incarcerated youth.'
Most nonheterosexual youths are "invisible" and will pass through pediatricians' offices without raising the issue of sexual orientation on their own. Therefore, health care professionals should raise issues of sexual orientation and sexual behavior with all adolescent patients or refer them to a colleague who can. Such discussions normalize the notion that there is a range of sexual orientation. The portrayal of openly gay or lesbian characters in media is starting to change how adolescents view these differences. Even adolescents who are quite sure of their own heterosexuality are likely to have friends, relatives, teachers, etc whom they know or suspect to be gay or lesbian or who are struggling with questions about their sexual orientation. Rather than asking patients whether they have a "boyfriend" or "girlfriend," pediatricians could ask, "Have you ever had a romantic relationship with a boy or a girl?" or "When you think of people to whom you are sexually attracted, are they men, women, both, neither, or are you not sure yet?" By doing so, pediatricians open the door to additional communication and start to break down stereotypes and stigmatization. It implies that any of the options is possible and that an adolescent may not be sure of his or her sexual orientation. If these issues are addressed, specifically targeted medical screening, medical treatment, and anticipatory guidance can be provided to adolescents who need it. Pediatricians can have an important positive effect on young people and their families by addressing sexual orientation and sexual behavior on several levels: office and hospital policies, clinical care, and community advocacy. 2
OFFICE PRACTICE: ENSURE A SAFE AND SUPPORTIVE ENVIRONMENT
A pediatric encounter may give adolescents a rare opportunity to discuss their concerns about their sexual orientation and/or activities. Adolescents' level of comfort in the pediatric office sets the tone for their other health care interactions. The way sexuality and other important personal issues are dis- cussed also sets an example for all adolescents and their parents. In the office, pediatricians are encouraged to 28:
1. Assure the patient that his or her confidentiality is protected 29
2. Implement policies against insensitive or inappropriate jokes and remarks by office staff.
3. Be sure that information forms use gender-neutral, nonjudgmental language.
4. Consider displaying posters, brochures, and information on bulletin boards that demonstrate sup- port of issues important to nonheterosexual youth and their families (eg, the American Academy of Pediatrics [AAPj brochure "Gay, Lesbian, and Bi- sexual Teens: Facts for Teens and their Parents").
5. Provide information about support groups and other resources to nonheterosexual youth and their friends and families if requested.
COMPREHENSIVE HEALTH CARE FOR ALL ADOLESCENTS
Pediatricians are not responsible for labeling or even identifying nonheterosexual youth. Instead, the pediatrician should create a clinical environment in which clear messages are given that sensitive personal issues including sexual orientation can be dis- cussed whenever the adolescent feels ready to do so. A major obstacle to effective medical care is adolescents' misunderstanding of their right to confidential care.30 The pediatrician should be ready to raise and discuss issues of sexual orientation with all adolescents, particularly those in distress or engaged in high-risk behaviors. The pediatrician should be able to explore the adolescent's understanding and concerns about sexual orientation, dispel any misconceptions, provide appropriate medical care and anticipatory guidance, and connect the adolescent to appropriate supportive community resources. Pediatricians are encouraged to 29,31 :
1. Be aware of the special issues surrounding the development of sexual orientation.29
2. Assure the patient that his or her confidentiality is protected.29
3. Discuss emerging sexuality with all adolescents. 32
* Be knowledgable that many heterosexual youth also may have sexual experiences with people of their own sex. Labeling as homosexual an adolescent who has had sexual experiences with persons of the same sex or is questioning his or her sexual orientation could be premature, inappropriate, and counterproductive.
* Use gender-neutral language in discussing sexuality; use the word "partner" rather than "boyfriend" or "girlfriend," and talk about "protection" rather than just "birth control."
*Give evidence of support and acceptance to adolescents questioning their sexual orientation. Provide information and resources regarding gay, lesbian, and bisexual issues to all interested adolescents.
* Ask all adolescents about risky behaviors, depression, and suicidal thoughts.
*Encourage abstinence, discourage multiple partners, and provide "safer sex" guidelines to all adolescents.33 Discuss the risks associated with anal intercourse for those who choose to engage in this behavior, and teach them ways to de- crease risk.
* Counsel all adolescents about the link between substance use (alcohol, marijuana, and other drugs) and unsafe sexual intercourse.
* Ask all adolescents about personal experience with violence including sexual or intimate-partner violence.
Provide additional screening and education as indicated for each adolescent's sexual activity:
-
STD testing from appropriate sites 34
-
HIV testing with appropriate support and counseling 35
-
Pregnancy testing and counseling36,37
-
Papanicolaou testing
-
Hepatitis B and, when appropriate, hepatitis A immunization
referred or with whom you consult are respectful of the range of adolescents' sexual orientation.
4. Ensure that colleagues to whom adolescents are referred or with whom you consult are respectful of the range of adolescents' sexual orientation.
SPECIAL CONSIDERATIONS FOR NONHETEROSEXUAL YOUTH
For adolescents who self-identify as gay, lesbian, or bisexual, pediatricians should be particularly aware of several points:
1. Be prepared to refer adolescents' care if you have personal barriers to providing such care. Many individuals have strong negative attitudes about homosexuality or may simply feel uncomfortable with the subject. Even discomfort expressed through body language can send a very damaging message to nonheterosexual youth. It is an ethical and professional obligation to make an appropriate referral in these situations for the good of the child or adolescent.
2. Assure the patient that his or her confidentiality is protected.29 Discuss with adolescents and, if appropriate, their parents whether they wish to have their sexual orientation recorded in office and hospital charts. Many nonheterosexual adults prefer to have this information recorded so that health care professionals will not assume heterosexuality.
3. Help the adolescent think through his or her feelings carefully; strong same-sex feelings and even sexual experiences can occur at this age and do not define sexual orientation.
4. Carefully identify all risky behaviors (sexual behaviors; use of tobacco, alcohol, and drugs; etc) and offer advice and treatment if indicated.
5. Ask about mental health concerns and evaluate or refer patients with identified problems.
6. Offer support and advice to adolescents faced with or anticipating conflicts with families and/or friends.
7. Encourage transition to adult health care when age-appropriate.
Pediatricians should be aware that the revelation of an adolescent's homosexuality (also called disclosure or "coming out") has the potential for intense family discord. 1,2,28 In many families, it precipitates physical and/or emotional abuse or even expulsion. The pediatrician call advise the adolescent to use certain language that may be helpful at the time of disclosure, such as "I am the same person, you just know one more thing about me now." However, there is no one disclosure technique that will preclude negative reactions. Parents, siblings, and other family members may require professional help to deal with their confusion, anger, guilt, and feelings of loss, and professionals who work with adolescents may be required to intervene on the adolescent's behalf. If the pediatrician has a relationship with the parents from ongoing primary care, he or she can be an important initial source of support and information. However, adolescents should be counseled to think carefully about the consequences of disclosure and to take their time in sharing information that could have many repercussions. 1
With regard to parents of nonheterosexual adoles- cents, pediatricians are encouraged to:
1. Advise adolescents about whether, when, and how to disclose their nonheterosexuality to their parents. If unsure, assist the adolescent in finding a knowledgeable professional who can help.
2. Be knowledgeable about the process of disclosure.
1830 SEXUAL ORIENTATION AND ADOLESCENTS
3. Be supportive of parents of adolescents who have disclosed that they are not heterosexual. Most states have chapters of Parents and Friends of Lesbians and Gays (PFLAG) to which interested families may be referred.
4. Remind parents and adolescents that gay and les- bian individuals can be successful parents themselves. 38- 41
5. Be prepared to refer parents if you do not feel personally comfortable accepting this responsibility.
Despite AAP statements issued in 1983 42 and 1993 43 urging excellent clinical care for nonheterosexual adolescents, these patients still experience many risks to their physical and mental health and safety that occur outside the scope of usual office practice. Some pediatricians may wish to take a broader role in their communities to help decrease these risks. Pediatricians could model and provide opportunities for increasing awareness and knowledge of homosexuality and bisexuality among school staff, mental health professionals, and other community leaders. They can make themselves available as resources for community HIV and acquired immunodeficiency syndrome (AIDS) education and pre- vention activities. It is critical that schools find a way to create safe and supportive environments for stu- dents who are or wonder about being nonhetero- sexual or who have a parent or other family member who is nonheterosexual. Support from respected pe- diatricians can facilitate these efforts greatly. Pedia- tricians who choose to be active on these issues may wish to 2,2B:
1. Help raise awareness among school and community leaders of issues relevant to nonheterosexual youth.
2. Help with the discussion of when and how factual materials about sexual orientation should be included in school curricula and in school and community libraries.
-
Support the development and maintenance of school- and community-based support groups for nonheterosexual students and their friends and parents.
-
Support HIV and AIDS prevention and education efforts.
-
Develop and/or request continuing education opportunities for health care professionals related to issues of sexual orientation, nonheterosexual youth, and their families.
SUMMARY OF PHYSICIAN GUIDELINESThe AAP reaffirms the physician's responsibility to provide comprehensive health care and guidance in a safe and supportive environment for all adolescents, including nonheterosexual adolescents and young people struggling with issues of sexual orientation. Some pediatricians might choose to assume the additional role of advocating for nonheterosexual youth and their families in their communities. The deadly consequences of HIV and AIDS, the damaging effects of violence and ostracism, and the increased prevalence of adolescent suicidal behavior underscore the critical need to address and seek to prevent the major physical and mental health problems that confront nonheterosexual youths in their transition to a healthy adulthood.
COMMITTEE ON ADOLESCENCE, 2002-2003
David W. Kaplan, MD, MPH, Chairperson
Angela Diaz, MD
Ronald A. Feinstein, MD
Martin M. Fisher, MD Jonathan D. Klein, MD, MPH W. Samuel Yancy, MD
PAST COMMITTEE MEMBERS
Luis F. Olmedo, MD
Ellen S. Rome, MD, MPH
LIAISONS
S. Paige Hertweck, MD
American College of Obstetricians and
Gynecologists Glen Pearson, MD
American Academy of Child and Adolescent
Psychiatry
Miriam E. Kaufman, MD
Canadian Paediatric Society
Barbara L. Frankowski, MD, MPH
Past Liaison to Section on School Health
Diane G. Sacks, MD
Past Liaison From Canadian Paediatric Society
CONSULTANT
Ellen C. Perrin, MD
STAFF
Karen S. Smith
REFERENCES
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2. Perrin EC. Sexual Orientation in Child and Adolescent Health Care. New York, NY: Kluwer Academic/Plenum Publishers; 2002
3.Sell RL, Becker JB. Sexual orientation data collection and progress toward Healthy People 2010. Am J Public Health. 2001;91:876-882
4 Friedman RC, Downey JI. Homosexuality. N Engl J Med. 1994;331: 923-930
5. Stronski Huwiler SM, Remafedi G. Adolescent homosexuality. Adv Pedistr. 1998;45:107-144
6. Bell AP, Weinberg MS. Hotnosexualities: A Study of Diversity Among Men and Women. New York, NY: Simon and Shuster; 1978
7. Jay K, Young A. The Gay Report: Lesbians and Gay Men Speak Out About Their Sexual Experiences and Lifestyles. New York, NY: Summitt Books; 1979
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Rowlett JD, Patel D, Greydanus DE. Homosexuality. In: Greydanus DE, Wolraich ML, eds. Behavioral Pediatrics. New York, NY: Springer-Verlag; 1992:37-54
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Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior in the Human Male. Philadelphia, PA: WB Saunders Co; 1948
10. Remafedi C, Resnick M, Blum it, Harris L. Demography of sexual orientation in adolescents. Pediatrics. 1992;89:714-721
11. Savin-Williams RC. Theoretical perspectives accounting for adolescent homosexuality. J Adolesc Health Care. 1988;9:95-104
12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Revised. Washington, DC: American Psychi- atric Association; 1987
13. Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior in the Human Female. Philadelphia, PA: WB Saunders Co; 1953
14. Seidman SN, Reider RO. A review of sexual behavior in the United States. Am J Psychiatry. 1994;151:330-341
15. Sorenson RC. Adolescent Sexuality in Contemporary America. New York, NY: World Publishing; 1973
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Garofalo R, Wolf RC, Wissow LS, Woods ER, Goodman E. Sexual orientation and risk of suicide attempts among a representative sample of youth. Arch Pediatr Adolesc Med. 1999;153:487-493
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Kreiss JL, Patterson DL. Psychosocial issues in primary care of lesbian, gay, bisexual, and transgender youth. J Pediatr Health Care. 1997;11: 266-274
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Remafedi G. Adolescent homosexuality: psychosocial and medical im- plications. Pediatrics. 1987;79:331-337
19. Russell ST, Franz BT, Driscoll AK. Same-sex romantic attraction and experiences of violence in adolescence. Am J Public Health. 2001;91: 903-906
20. Garofalo R, Wolf RC, Kessel S, Palfrey SJ, DuRant RH. The association between health risk behaviors and sexual orientation among a school- based sample of adolescents. Pediatrics. 1998;101:895-902
21. Valleroy LA, MacKellar DA, Karon JM, et al. HIV prevalence and associated risks in young men who have sex with men. JAMA. 2000; 284:198-204
22. Remafedi G, Farrow JA, Deisher RW. Risk factors for attempted suicide ,in gay and bisexual youth. Pediatrics. 1991;87:869-875
23. Faulkner All, Cranston K. Correlates of same-sex sexual behavior in a random sample of Massachusetts high school students. Are j Public Health. 1998;88:262-266
24. Remafedi G, French S, Story M, Resnick MD, Blum R. The relationship between suicide risk and sexual orientation: results of a population- based study. Am J Public Health. 1998;88:57-60
25. Remafedi C. Sexual orientation and youth suicide. JAMA. 1999;282: 1291-1292
26, French SA, Story M, Remafedi G, Resnick MD, Blum RW. Sexual orientation and prevalence of body dissatisfaction and eating disordered behaviors: a population-based study of adolescents. lnt J Eat Visaed. 1996;19:119-126
27. Savin-Williams RC, Cohen KM. The Lives of Lesbians, Gays, and Bisexuals: Children to Adults, Fort Worth, TX: 'Harcourt Brace College Publishing; 1996
28. Perrin EC. Pediatricians and gay and lesbian youth. Pediatr Rev. 1996; 17:311-318
29. American Academy of Pediatrics. Confidentiality in adolescent health care. AAP News. April 1989:9. Reaffirmed January 1993
30. Allen LB, Glicken AD, Beach RK, Naylor KB. Adolescent health care experience of gay, lesbian, and bisexual young adults. J Adolesc Health. 1998;23:212-220
31. Ryan C, Futterman D. Caring for gay and lesbian teens. Cantemp Pediatr. 1998;15:107-130
32. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence. Sexuality education for children and adolescents. Pediatrics. 2001;108: 498-502
33. American Academy of Pediatrics, Committee on Adolescence. Condom use by adolescents. Pediatrics. 2001;107:1463-1469
34. American Academy of Pediatrics, Committee on Adolescence. Sexually transmitted diseases. Pediatrics. 1994,94:568-572
35. American Academy of Pediatrics, Committee on Pediatric AIDS and Committee on Adolescence. Adolescents and human immunodeficiency virus infection: the role of the pediatrician in prevention and intervention. Pediatrics. 2001;107:188-190
36. American Academy of Pediatrics, Committee on Adolescence. Counsel- ing the adolescent about pregnancy options. Pediatrics. 1998;101: 938-940
37. American Academy of Pediatrics, Committee on Adolescence. Adolescent pregnancy-current trends and issues: 1998. Pediatrics. 1999;103: 516-520
38. Gold MA, Perrin EC, Futterman D, Friedman SB. Children of gay or lesbian parents. Pediatr Rev. 1994;15:354-358
39. Perrin EC. Children whose parents are lesbian or gay. Cantemp Pediatr. 1998;15:113-130
40. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. Coparent or second-parent adoption by same-sex parents. Pediatrics. 2002;109:339-340
41. Benkov L. Reinventing the Family: The Emerging Story of Lesbian and Gay Parents. New York, NY: Crown Publishers; 1994
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American Academy of Pediatrics, Committee On Adolescence. Homo- sexuality and adolescence. Pediatrics. 1983;72:249-250
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American Academy of Pediatrics, Committee on Adolescence. Homo- sexuality and adolescence. Pediatrics. 1993;92:631-634
All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
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ATTACHMENT B American Psychological Association
Answers to Your Questions About Sexual Orientation and Homosexuality http://www.apa.org/topics/orientation.html
AMERICAN PSYCHOLOGICAL ASSOCIATION
Answers to Your Questions About Sexual Orientation and Homosexuality
What Is Sexual Orientation?
What Causes a Person To Have a Particular Sexual Orientation?
Is Sexual Orientation a Choice?
Can Therapy Change Sexual Orientation?.
What About So-Called 'Conversion Therapies"?
Is Homosexuality a MentaI Illness or Emotional Problem?
Can Lesbians, Gay Men, and Bisexuals Be Good Parents?
Why Do Some Gay Men, Lesbians and Bisexuais Tell People About Their Sexual Orientation?
Why Is the "Coming Out"_Process Difficult for Some Gay, Lesbian and.Bisexual People?
What Can Be_Done to Overcome the Prejudice and Discrimination the Gay, Men Lesbians, and Bisexuals
Experience?
Why is it important for Society to be Better Educated About Homosexuality?
Are All Gay and.Bisexual Men HIV Infected?
Where Can I Find More Information About Homosexuality?
What Is Sexual Orientation?
Sexual Orientation is an enduring emotional, romantic, sexual or affectional attraction to another person. It is easily distinguished from other components of sexuality including biological sex, gender identity (the psychological sense of being male or female) and the social gender role (adherence to cultural norms for feminine and masculine behavior).
Sexual orientation exists along a continuum that ranges from exclusive homosexuality to exclusive heterosexuality and includes various forms of bisexuality. Bisexual persons can experience sexual, emotional and affectional attraction to both their own sex and the opposite sex. Persons with a homosexual orientation are sometimes referred to as gay (both men and women) or as lesbian (women only).
Sexual orientation is different from sexual behavior because it refers to feelings and self-concept. Persons may or may not express their sexual orientation in their behaviors.
What Causes a Person To Have a Particular Sexual Orientation?
There are numerous theories about the origins of a person's sexual orientation; most scientists today agree that sexual orientation is most likely the result of a complex interaction of environmental, cognitive and biological factors. In most people, sexual orientation is shaped at an early age. There is also considerable recent evidence to suggest that biology, including genetic or inborn hormonal factors, play a significant role in a person's sexuality. in summary, it is important to recognize that there are probably many reasons for a person's sexual orientation and the reasons may be different for different people.
Is Sexual Orientation a Choice?
No, human beings can not choose to be either gay or straight. Sexual orientation emerges for most people in early adolescence without any prior sexual experience. Although we can choose whether to act on our feelings, psychologists do not consider sexual orientation to be a conscious choice that can be voluntarily changed.
Can Therapy Change Sexual Orientation?
No. Even though most homosexuals live successful, happy lives, some homosexual or bisexual people may seek to change their sexual orientation through therapy, sometimes pressured by the influence of family members or religious groups to try and do so. The reality is that homosexuality is not an illness. It does not require treatment and is not changeable.
However, not all gay, lesbian, and bisexual people who seek assistance from a mental health professional want to change their sexual orientation. Gay, lesbian, and bisexual people may seek psychological help with the coming out process or for strategies to deal with prejudice, but most go into therapy for the same reasons and life issues that bring straight people to mental health professionals.
What About So-Called "Conversion Therapies"?
Some therapists who undertake so-called conversion therapy report that they have been able to change their clients' sexual orientation from homosexual to heterosexual. Close scrutiny of these reports however show several factors that cast doubt on their claims. For example, many of the claims come from organizations with an ideological perspective which condemns homosexuality. Furthermore, their claims are poorly documented. For example, treatment outcome is not followed and reported overtime as would be the standard to test the validity of any mental health intervention.
The American Psychological Association is concerned about such therapies and their potential harm to patients. In 1997, , the Association's Council of Representatives passed a resolution reaffirming psychology's opposition to homophobia in treatment and spelling out a client's right to unbiased treatment and self-determination. Any person who enters into therapy to deal with issues of sexual orientation has a right to expect that such therapy would take place in a professionally neutral environment absent of any social bias.
Is Homosexuality a Mental Illness or Emotional Problem?
No. Psychologists, psychiatrists and other mental health professionals agree that homosexuality is not an illness, mental disorder or an emotional problem. Over 35 years of objective, well-designed scientific research has shown that homosexuality, in and itself, is not associated with mental disorders or emotional or social problems. Homosexuality was once thought to be a mental illness because mental health professionals and society had biased information. In the past the studies of gay, lesbian and bisexual people involved only those in therapy, thus biasing the resulting conclusions. When researchers examined data about these people who were not in therapy, the idea that homosexuality was a mental illness was quickly found to be untrue.
In 1973 the American Psychiatric Association confirmed the importance of the new, better designed research and removed homosexuality from the official manual that lists mental and emotional disorders. Two years later, the American Psychological Association passed a resolution supporting the removal. For more than 25 years, both associations have urged all mental health professionals to help dispel the stigma of mental illness that some people still associate with homosexual orientation.
Can Lesbians, Gay Men, and Bisexuals Be Good Parents?
Yes. Studies comparing groups of children raised by homosexual and by heterosexual parents find no developmental differences between the two groups of children in four critical areas: their intelligence, psychological adjustment, social adjustment, and popularity with friends. It is also important to realize that a parent's sexual orientation does not dictate his or her children's.
Another myth about homosexuality is the mistaken belief that gay men have more of a tendency than heterosexual men to sexually molest children. There is no evidence to suggest that homosexuals are more likely than heterosexuals to molest children.
Why Do Some Gay Men, Lesbians and Bisexuals Tell People About Their Sexual Orientation?
Because sharing that aspect of themselves with others is important to their mental health. In fact, the process of identity development for lesbians, gay men and bisexuals called "coming out", has been found to be strongly related to psychological adjustment-the more positive the gay, lesbian, or bisexual identity, the better one's mental health and the higher one's self-esteem.
Why Is the "Coming Out" Process Difficult for Some Gay, Lesbian and Bisexual People?
For some gay and bisexual people the coming out process is difficult, for others it is not. Often lesbian, gay and bisexual people feel afraid, different, and alone when they first realize that their sexual orientation is different from the community norm. This is particularly true for people becoming aware of their gay, lesbian, or bisexual orientation as a child or adolescent, which is not uncommon. And, depending on their families and where they live, they may have to struggle against prejudice and misinformation about homosexuality. Children and adolescents may be particularly vulnerable to the deleterious effects of bias and stereotypes. They may also fear being rejected by family, friends, co-workers, and religious institutions. Some gay people have to worry about losing their jobs or being harassed at school if their sexual orientation became well known. Unfortunately, gay, lesbian and bisexual people are at a higher risk for physical assault and violence than are heterosexuals. Studies done in California in the mid 1990s showed that nearly one-fifth of all lesbians who took part in the study and more than one-fourth of all gay men who participated had been the victim of a hate crime based on their sexual orientation. In another California study of approximately 500 young adults, half of all the young men participating in the study admitted to some form of anti-gay aggression from name-calling to physical violence.
What Can Be Done to Overcome the Prejudice and Discrimination the Gay Men, Lesbians, and Bisexuals Experience?
Research has found that the people who have the most positive attitudes toward gay men, lesbians and bisexuals are those who say they know one or more gay, lesbian or bisexual person well-often as a friend or co-worker. For this reason, psychologists believe negative attitudes toward gay people as a group are prejudices that are not grounded in actual experiences but are based on stereotypes and prejudice.
Furthermore, protection against violence and discrimination is very important, just as it is for other minority groups. Some states include violence against an individual on the basis of his or her sexual orientation as a "hate crime" and 10 U.S. states have laws against discrimination on the basis of sexual orientation.
Why is it Important for Society to be Better Educated About Homosexuality?
Educating all people about sexual orientation and homosexuality is likely to diminish anti-gay prejudice. Accurate information about homosexuality is especially important to young people who are first discovering and seeking to understand their sexuality-whether homosexual, bisexual, or heterosexual. Fears that access to such information will make more people gay have no validity-information about homosexuality does not make someone gay or straight.
Are All Gay and Bisexual Men HIV Infected?
No. This is a commonly held myth. In reality, the risk of exposure to HIV is related to a person's behavior, not their sexual orientation. What's important to remember about HIV/AIDS is it is a preventable disease through the use of safe sex practices and by not using drugs.
Where Can I Find More Information About Homosexuality?
APA Lesbian, Gay, and Bisexual Concerns Program
750 First Street, NE. Washington, DC 20002
Email: LGBC
National Gay and Lesbian Task Force
2320 17th St. Washington, DC 20009 (202) 332-6483 Email: NGLTF
Parents, Families and Friends of Lesbians and Gays
1726 M Street, NW, Suite 400, Washington, DC 20036 (202) 467-8180
Email: PFLAG
Sexuality Information and Education Council of the United States
130 W 42nd St., Ste. 350 New York, NY 10036 (212)-819-9770 Email: SIECUS
2007 American Psychological Association
750 First Street, NE, Washington, DC 20002-4242
Telephone: 800-374-2721; 202-336-5500. TDD/TTY: 202-336-6123
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ATTACHMENT C
American Medical Association
Policy Number H-160.9916 Health Care Needs of the Homosexual
Population
http://www.ama-assn.org/ama/pub/category/14754.html
AMA Policy Number H-160.991 Health Care Needs of the Homosexual Population.
Our AMA: (1) believes that the physician's nonjudgmental recognition of sexual orientation and behavior enhances the ability to render optimal patient care in health as well as in illness. In the case of the homosexual patient this is especially true, since unrecognized homosexuality by the physician or the patient's reluctance to report his or her sexual orientation and behavior can lead to failure to screen, diagnose, or treat important medical problems. With the help of the gay and lesbian community and through a cooperative effort between physician and the homosexual patient effective progress can be made in treating the medical needs of this particular segment of the population; (2) is committed to taking a leadership role in: (a) educating physicians on the current state of research in and knowledge of homosexuality and the need to take an adequate sexual history; these efforts should start in medical school, but must also be a part of continuing medical education; (b) educating physicians to recognize the physical and psychological needs of their homosexual patients; (c) encouraging
the development of educational programs for homosexuals to acquaint them with the diseases for which they are at risk; (d) encouraging physicians to seek out local or national experts in the health care needs of gay men and lesbians so that all physicians will achieve a better understanding of the medical needs of this population; and (e) working with the gay and lesbian community to offer physicians the opportunity to better understand the medical needs of homosexual and bisexual patients; and (3) opposes, the use of "reparative" or "conversion" therapy that is based upon the assumption that homosexuality per se is a mental disorder or based upon the a priori assumption that the patient should change his/her homosexual orientation. (CSA Rep. C, 1-81; Reaffirmed: CLRPD Rep. F,. 1-91; CSA Rep. 8 - 1-94; Appended: Res. 506, A-00)
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