4
Childhood/Adolescence

To understand the context of a person’s life course, it is critical to understand the age cohort to which that individual belongs. Youth growing up today will see changes that earlier generations of lesbians and gay men would never have expected in their lifetimes, including politicians, business leaders, and educators who are openly gay; marriage between same-sex couples; and an evolving popular and artistic culture that provides many positive portrayals of lesbian and gay characters in movies and plays, on television, and in literature. Today’s youth are able to use the Internet to retrieve online information about LGBT issues, providing social networking opportunities and access to knowledge in a way that was not available to older cohorts. At the same time, young LGBT people searching the Internet and interacting with their peers will be aware of the pervasive negative views of sexual and gender minorities.

Likewise, many transgender elders did not even know as children that other transgender people existed, and certainly received little acknowledgment of their transgender feelings. By contrast, many transgender children and adolescents today have role models (either in the media or in real life), and their gender-variant expression is often sufficient for parents to obtain more information and access existing networks of families with gender-variant children. Moreover, transgender youth today have access to early medical intervention to alleviate any gender dysphoria (defined as discomfort with one’s sex assigned at birth) they might experience.

In this report, childhood and adolescence encompasses the life course through the emergence of adulthood, generally understood by the committee to occur in the early 20s. During this phase of life, a person, regardless



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4 Childhood/Adolescence T o understand the context of a person’s life course, it is critical to understand the age cohort to which that individual belongs. Youth growing up today will see changes that earlier generations of lesbi- ans and gay men would never have expected in their lifetimes, including politicians, business leaders, and educators who are openly gay; marriage between same-sex couples; and an evolving popular and artistic culture that provides many positive portrayals of lesbian and gay characters in movies and plays, on television, and in literature. Today’s youth are able to use the Internet to retrieve online information about LGBT issues, providing social networking opportunities and access to knowledge in a way that was not available to older cohorts. At the same time, young LGBT people searching the Internet and interacting with their peers will be aware of the pervasive negative views of sexual and gender minorities. Likewise, many transgender elders did not even know as children that other transgender people existed, and certainly received little acknowledg- ment of their transgender feelings. By contrast, many transgender children and adolescents today have role models (either in the media or in real life), and their gender-variant expression is often sufficient for parents to obtain more information and access existing networks of families with gender- variant children. Moreover, transgender youth today have access to early medical intervention to alleviate any gender dysphoria (defined as discom- fort with one’s sex assigned at birth) they might experience. In this report, childhood and adolescence encompasses the life course through the emergence of adulthood, generally understood by the commit- tee to occur in the early 20s. During this phase of life, a person, regardless 141

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142 THE HEALTH OF LGBT PEOPLE of his or her sexual orientation or gender identity, develops from a child who must be cared for to a self-reliant individual. The developmental changes that occur are complex, particularly with the onset of puberty. LGBT youth face the same challenges as their heterosexual peers, but also stigma that may contribute to the identified disparities in health status be- tween sexual- and gender-minority youth and heterosexual youth. The ability to address these disparities is hampered by our lack of knowledge about LGBT youth. One of the challenges of discussing the development of children and adolescents who are LGBT is that beliefs and biases have often precluded substantive research. Not long ago, for example, a prevailing notion was that one’s sexual identity and orientation did not emerge until late adolescence and that an attraction to people of the same sex was likely a passing phase (Money, 1990). Moreover, efforts to survey young people about their sexual orientation have been fraught with difficulties at both the institutional review board and community levels. These barriers have impeded important developmental research. While the current state of knowledge regarding the health of LGBT youth is derived from limited research, it is worth noting that much of this research has focused on mental health; little research has been conducted on the physical health of LGBT youth because, like most other youth, they generally do not struggle with chronic diseases that impact their physical health. As mentioned in previous chapters, the disparities in both mental and physical health that are seen between LGBT and heterosexual and non-gender-variant youth are influenced largely by their experiences of stigma and discrimination during the development of their sexual orienta- tion and gender identity and throughout the life course. This chapter begins with a discussion of the development of sexual orientation and gender identity in LGBT youth. The chapter then reviews the research on mental health and then physical health in these youth. Risk and protective factors and health services are then addressed in turn. The chapter next examines contextual influences, such as demographic charac- teristics and the role of the family. The chapter concludes with a summary of key findings and research opportunities. Of note, the chapter emphasizes adolescence rather than childhood because of the limited research available on younger children’s and pre-adolescents’ awareness of, feelings about, and experiences with being LGBT. DEVELOPMENT OF SEXUAL ORIENTATION AND GENDER IDENTITY Adolescents are engaged in an ongoing process of sexual development (Rosario et al., 2008); many adolescents may be unsure of their sexual ori- entation, while others have been clear about it since childhood. This ongo-

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143 CHILDHOOD/ADOLESCENCE ing process suggests that for some adolescents, self-identification of sexual orientation and the sex of sexual partners may change over time and may not necessarily be congruent (Saewyc et al., 2004). The development of sexual identity in lesbian, gay, and bisexual indi- viduals is a unique process that has been widely reported in the scientific literature and popular culture but has received surprisingly little empirical attention. Early models of sexual identity development were generated on the basis of retrospective descriptions by adults. Models of homosexual identity development proposed by Cass (1979) and Troiden (1989) describe a staged process that (1) recognizes the impact of stigma that affects both the formation and expression of homosexual identity, (2) unfolds over a period of time, (3) involves increasing acceptance of a homosexual identity, and (4) includes disclosure to other persons. However, these models were developed at a time in which access to information about sexual orientation was limited; negative attitudes about homosexuality were more prevalent; and few resources existed for the study of LGB populations, particularly adolescents. Furthermore, the development of these theoretical models was based on the retrospective experiences of white adults. The first study to explore the development of adolescent lesbian and gay identity in depth included 202 LGB adolescents, more than half of whom were racial minority youth (Herdt and Boxer, 1993). The mean age of self-identification as lesbian or gay was 16.7 years for males and 16 years for females. Gay males were, on average, aware of same-sex attraction at about age 9; the average age for lesbians was 10. Based on the results of their study, the researchers concluded that sexual identity development should be viewed as an ongoing process rather than as a series of stages or phases. Investigators who conducted early work on the development of sexual orientation identity argued that coming out or self-identifying as lesbian or gay during adolescence may be a developmental process seen only in contemporary LGB youth—one that may have unique consequences for later life-course development compared with lesbian and gay adults who did not come out during adolescence (Boxer and Cohler, 1989). Herdt and Boxer (1993) document the process of transition from a heterosexual to a gay identity in the context of LGB cultural supports (social institutions, a gay youth program, lesbian and gay adult role models). Boxer and Cohler (1989) observe that one of the major developmental tasks for lesbian and gay youth is the deconstruction of previously internalized heterosexual ex- pectations and the construction of a new set of future expectations of the gay and lesbian life course. A range of investigators have focused on “milestones” as indicators of sexual identity development among LGB adolescents. These include age of awareness of sexual attraction; age of self-labeling as lesbian, gay, or

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144 THE HEALTH OF LGBT PEOPLE bisexual; age of disclosure of same-sex orientation; and age of first sexual experience. Research subsequent to Herdt and Boxer’s early work found comparable ages of first awareness of sexual attraction (i.e., approximately age 10) (e.g., D’Augelli, 2006; D’Augelli and Hershberger, 1993; Rosario et al., 1996). “Coming out” or self-identifying and subsequently sharing that identity with others is a process that occurs in a social and historical context. Earlier literature indicates that this experience may be especially challenging for young people who come out during adolescence, given the need to integrate an LGB identity with other aspects of identity development in the context of social stigma and discrimination. However, little current research is avail- able to show how this process might differ for contemporary adolescents as a result of increased awareness, greater access to information, and changes in media representation of LGB people. More research is needed to under- stand the process of coming out for diverse populations of LGB youth. Similarly, little research has focused on sexual identity development among ethnically diverse LGB adolescents. Development experiences may differ as adolescents negotiate both ethnic and sexual orientation identity. One community-based study of 145 white, black, and Latino LGB youth aged 14–21 found no differences in sexual identity, current sexual orienta- tion, or comfort with and acceptance of sexual identity among the three racial groups (Rosario et al., 2004). However, black youth were involved in fewer gay-related social activities, were less comfortable with others knowing about their sexual identity, and disclosed their sexual orientation to fewer persons than their white peers. While Latino youth disclosed their LGB identity to fewer people than white or black youth, they were more comfortable with others knowing about their LGB identity than members of the other racial groups. More recent research examined ethnic and sexual identity development during adolescence among 22 black and Latino gay youth aged 16–22 (Jamil et al., 2009). The researchers found that ethnic and sexual identity developed concurrently during adolescence, but the processes were differ- ent and not related. Ethnic identity development was shaped by growing awareness of the youth’s ethnic and cultural heritage and was supported by peers; family members; and cultural markers such as food, music, and holidays. Sexual identity development was supported by community-based organizations, peers, and information from the Internet. Sexual identity development was described as a private process, while ethnic identity de- velopment was viewed as a more public process. The ongoing process of sexual development among adolescents pres- ents challenges to the collection of data on the size of the population of LGB youth, although some studies using large samples of adolescents have examined the prevalence of same-sex attraction, same-sex sexual behavior,

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145 CHILDHOOD/ADOLESCENCE and LGB identities. In the 1999 wave of the Growing Up Today Study (n 5 10,685), a national survey of adolescents aged 12–17, approximately 1 percent of adolescents identified as homosexual or bisexual (n 5 103), with 5 percent identifying as mostly heterosexual (n 5 511) and 2 percent identifying as unsure (n 5 226) (Austin et al., 2004a). In the first wave of the National Longitudinal Study of Adolescent Health, conducted among 7th- through 12th-grade adolescents (n 5 11,940), 5 percent of females and about 7.3 percent of males reported same-sex romantic or sexual attractions (Russell and Joyner, 2001). DuRant and colleagues (1998), reporting on the prevalence of reported same-sex sexual behavior using the 1995 wave of the Vermont Youth Risk Behavior Survey (n 5 3,886 sexually active 8th- through 12th-grade males), found that 8.7 percent of high school males reported having had at least one same-sex partner (DuRant et al., 1998). Similar to sexual orientation identity, gender expression is not neces- sarily constant throughout childhood development. Gender variance, as it relates to expressing and exploring gender identity and gender roles, is a part of normal development. A relatively small percentage of gender-variant children develop an adult transgender identity (Green, 1987; Wallien and Cohen-Kettenis, 2008; Zucker and Bradley, 1995). However, research shows that the majority of adolescents with a gender-variant identity develop an adult transgender identity (Wallien and Cohen-Kettenis, 2008). Data on the prevalence of childhood gender-variant or transgender identities are severely limited, largely because there is no national database available to collect such data. A relatively small number of studies using nonprobability samples have attempted to assess the incidence of childhood gender-variant identities. One such study, discussed in Chapter 2, found that 1 percent of parents of boys aged 4–11 reported that their son wished to be of the other sex; for girls, the percentage was 3.5 percent (Zucker et al., 1997). Other studies using small nonprobability samples have documented trends in referrals to gender identity clinics by gender and persistence of gender identity concerns into adolescence and adulthood. One study ex- amining children aged 3–12 with gender identity issues in a Toronto clinic (n 5 358) and a Utrecht clinic (n 5 130) showed that boys were referred more often and at an earlier age than girls for such concerns (Cohen- Kettenis et al., 2003). In another small study (n 5 77) examining psycho- sexual outcomes of gender-dysphoric children at age of referral and then at follow-up approximately 10 years later, 27 percent of those with child- hood gender identity concerns were still gender dysphoric (Wallien and Cohen-Kettenis, 2008). (It should be noted that at follow-up, 30 percent of the sample failed to respond to recruitment letters or were not traceable.) Research with small clinical samples of gender-variant children has shown that, compared with controls, gender-variant children have more difficulties with peer relationships (Zucker et al., 1997); this is the case particularly for

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146 THE HEALTH OF LGBT PEOPLE boys compared with girls (Cohen-Kettenis et al., 2003). Poor peer relations was found to be the strongest predictor of behavior problems in both gender- variant boys and girls (Cohen-Kettenis et al., 2003). One small study showed that children with gender identity disorder (n 5 25) may have a more anxious nature than gender-conforming children (n 5 25) (Wallien et al., 2007). Grossman and D’Augelli (2006) conducted focus groups with young self-identified transgender males and females aged 15–21 and explored fac- tors related to physical and mental health. In this qualitative study, most of the youth reported experiences of family and peers reacting negatively toward their gender-atypical behaviors. Therapy or counseling that aims to change an individual’s sexual orientation, often based on the presumption that LGBT orientation/identity is abnormal or unhealthy, is known as con- version or reparative therapy (Just the Facts Coalition, 2008). The nation’s most prominent medical and mental health professional organizations, including the American Medical Association, the American Psychiatric Association, and the American Psychological Association, oppose the use of conversion therapy with both youth and adults (AMA, 2010; American Psychiatric Association, 2000a). The American Psychological Association formed a task force to review peer-reviewed studies on efforts to change sexual orientation. The task force concluded that evidence is lacking for the effectiveness of efforts to change sexual orientation and that conversion therapy may cause harm to LGBT individuals by increasing internalized stigma, distress, and depression (American Psychological As- sociation, 2009). Instead, the task force expressed support for the use of affirmative, culturally competent therapy that helps those facing distress related to their sexual orientation cope with social and internalized stigma and strengthen their social support networks (American Psychological Association, 2009). MENTAL HEALTH STATUS As noted, most of the research conducted among LGBT youth has examined their mental health status. Although a small amount of the literature explores the process of sexual orientation and gender identity development among LGBT youth (see the preceding section), a greater por- tion of the literature focuses on sexual-minority youth’s risk for suicidality and depression; few studies examine the prevalence of mood, anxiety, or eating disorders in these populations. As discussed below, the lack of data in many areas of mental health demonstrates the need for further research on the mental health status of LGBT youth. It is important to note that LGBT youth are typically well adjusted and mentally healthy. Research based on probability samples with LGB youth consistently indicates that the majority do not report mental health

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147 CHILDHOOD/ADOLESCENCE problems (Mustanski et al., 2010b; Russell and Joyner, 2001). Regarding transgender youth, although no data from national probability samples are available, studies with sizable convenience samples indicate that many, if not most, of these youth do not report mental health problems (Clements- Nolle et al., 2001; Nuttbrock et al., 2010). Mood and Anxiety Disorders Most of the research that has been conducted on mental health disor- ders among LGBT youth has relied on symptom or distress scales rather than formal clinical diagnoses (Mustanski et al., 2010b). To the committee’s knowledge, only two published studies have assessed LGBT adolescents diagnostically. Fergusson and colleagues (1999) conducted a study in New Zealand on the risk of psychiatric disorder and suicidal behavior using data from a birth cohort. They found that, relative to youth who identified as heterosexual, youth who identified as lesbian, gay, or bisexual were between 1.8 and 2.9 times more likely to experience generalized anxiety disorder, major depression, and conduct disorder. It should be noted, however, that of the 1,007 youth surveyed, only 28 self-identified as LGB or described past relationships with same-sex partners (Fergusson et al., 1999). More recently, Mustanski and colleagues (2010b) administered a struc- tured diagnostic interview to a community sample of 246 LGBT youth. They found that, although the youth in the sample showed a higher preva- lence of Diagnostic and Statistical Manual of Mental Disorders, 4th edi- tion (DSM-IV) diagnoses compared with national data, the prevalence was similar to that among another sample of urban, ethnically diverse youth from the same geographic area. Depression and Suicidality Over the past decade, an increasing number of studies based on large probability samples have consistently found that LGB youth and youth who report same-sex romantic attraction are at increased risk for suicidal ideation and attempts, as well as depressive symptoms, in comparison with their heterosexual counterparts. These include both school-based, state-based, and national studies (Almeida et al., 2009; Birkett et al., 2009; Bontempo and D’Augelli, 2002; Garofalo et al., 1999; Jiang et al., 2010; Russell and Joyner, 2001; Saewyc et al., 2007). The results of these stud- ies suggest increased rates of suicidal ideation and attempts among LGB youth in comparison with heterosexual youth even after controlling for potentially confounding factors such as substance use and depression. These population-based studies followed more than two decades of community- based studies of LGB youth that showed elevated reported rates of suicidal

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148 THE HEALTH OF LGBT PEOPLE ideation and attempts and identified predictors of suicidality in these popu- lations, although it should be noted that, much as with the larger popula- tion of young people, it is a small group of LGB youth who report suicidal behavior. With few exceptions, the increased rate of suicidality among LGB youth in comparison with heterosexual youth is consistent across age groups (i.e., middle school, high school, and young adult populations), gender (i.e., male, female, transgender), race/ethnicity (e.g., white, black, Latino, Asian/ Pacific Islander, American Indian/Alaska Native), and differing definitions of sexual orientation (i.e., same-sex attraction, self-identification, and be- havior) (Almeida et al., 2009; Birkett et al., 2009; Bontempo and D’Augelli, 2002; Faulkner and Cranston, 1998; Garofalo et al., 1998, 1999; Jiang et al., 2010; Saewyc et al., 2007). However, evidence from longitudinal studies on suicidality over time among LGB youth is lacking. Some older evidence disputes the idea of increased rates of completed suicide among LGB youth. Two studies using postsuicide data found no as- sociation between suicide and sexual orientation (Rich et al., 1986; Shaffer et al., 1995). However, capturing information about sexual orientation is especially difficult postsuicide since adolescents who are highly conflicted about their sexual orientation may not share these concerns with others. Moreover, these studies examined completed suicides from more than 20 years ago, when it was more difficult to be openly gay during adolescence. In addition, results of two community-based studies suggest that some of the suicide attempts reported by LGB youth may not be life-threatening, but rather low-risk suicidal ideation or plans (Savin-Williams, 2001). These studies have been challenged for potentially drawing on relatively low-risk populations, however (Russell, 2003). Many risk factors, both general and LGB-specific, have been implicated in the increased rates of suicidal behavior among LGB youth (see the de- tailed discussion of risk factors for the health of LGBT youth later in this chapter). General risk factors have been implicated in suicidal behavior in the larger population of youth and tend to be high among LGB youth. They include depression, substance use, early sexual initiation, not feeling safe at school, cigarette smoking, and inadequate social support. These fac- tors may partially mediate the increased risk of suicidality for LGB youth, although results of studies on this association are mixed (Fergusson et al., 1999; Garofalo et al., 1999; Russell and Joyner, 2001). Specific factors related to sexual-minority status, including homophobic victimization and stress (Huebner et al., 2004; Safren and Heimberg, 1999; Savin-Williams and Ream, 2003), are associated with suicidal behavior. In a study of 528 self-identified LGB youth aged 15–19, D’Augelli and colleagues (2005) found that recognizing same-sex attraction, initiating same-sex sexual ac- tivity, or appearing gender nonconforming at earlier ages was associated

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149 CHILDHOOD/ADOLESCENCE with reported suicide attempts in LGB youth; this association may be ex- acerbated by experiences of victimization and maltreatment (Corliss et al., 2009; Friedman et al., 2006). Family rejection due to sexual orientation may also be associated with increased risk of suicidality. In the previously mentioned study of 528 LGB youth, greater childhood parental psychological abuse and parental efforts to discourage gender-atypical behavior were associated with increased risk of suicide attempts (D’Augelli et al., 2005). Similarly, a study of 224 self- identified LGB youth aged 21–25 found that higher rates of family rejection were associated with increased rates of reports of attempted suicide, high levels of depression, and risk behaviors (Ryan et al., 2009). Conversely, findings from a study of 245 Latino and non-Latino white self-identified LGBT youth (aged 21–25) suggest that family acceptance of and support- ive reactions to an adolescent’s LGBT identity may be protective against depression and suicidal ideation and attempts (Ryan et al., 2010). Using data from the 2004 Minnesota Student Survey of 9th and 12th graders (n 5 21,927), Eisenberg and Resnick (2006) found that family connected- ness, adult caring, and school safety may also be protective against suicidal ideation and attempts. Evidence from several large samples of middle and high school stu- dents suggests that the above LGB-specific factors, including victim- ization and perceived discrimination, largely mediate the association between sexual-minority status and both depressive symptoms and sui- cidal behavior (Almeida et al., 2009; Birkett et al., 2009; Bontempo and D’Augelli, 2002). Because large data sets have not measured whether people are trans- gender, information on suicidal behavior and depressive symptoms among transgender youth is limited to relatively small convenience samples. In a nonprobability sample of 515 transgender people (n 5 392 male-to-female and n 5 123 female-to-male), Clements-Nolle and colleagues (2006) found that 47 percent of participants younger than 25 (n 5 66) had a history of attempted suicide. Another study, of 55 transgender youth aged 15–21, found that 45 percent seriously thought about taking their lives, and 26 percent reported a history of life-threatening behavior (Grossman and D’Augelli, 2007). These studies suggest there is an elevated risk for depres- sion and attempted suicide among transgender youth. Limited cross-sectional research has explored mental health–related disparities among urban samples of transgender youth. Nuttbrock and col- leagues (2010) examined the life course of 571 transgender females aged 19–59 (separated into two age groups: 19–39 and 40–59). The authors found that gender-related interpersonal abuse was a significant health prob- lem in the sample. Among the younger group of transgender women, 15.6 percent reported an attempted suicide during adolescence. Among the older

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150 THE HEALTH OF LGBT PEOPLE group, 23.5 percent experienced major depression during adolescence. In addition, interpersonal abuse associated with gender atypicality, not infre- quently at the hands of parents or other family members, was associated with both major depression and suicidality as defined by DSM-IV. These associations, particularly with depression, were extremely strong during adolescence, and tended to decline over time but remain significant over the life course. Interventional approaches to prevent suicidality among LGBT youth have not been widely tested. The published literature includes suggestions to encourage greater awareness and appropriate treatment by health care providers (Kitts, 2005), psychotherapists (Hart, 2001), and school person- nel (Bontempo and D’Augelli, 2002); to educate and counsel parents and families to decrease rejecting and increase supportive behaviors (Ryan et al., 2010); or to use specific media to reach isolated youth, such as Web-based social networks (Silenzio et al., 2009). To the committee’s knowledge, how- ever, no specific interventions have been tested. In addition, little research has examined suicidality by race/ethnicity. Eating Disorders/Body Image A large cohort study provides some evidence that eating disorders fol- low gender-specific patterns among LGB youth. In data from the previously mentioned 1999 Growing Up Today Study (n 5 10,583 youth), lesbian and bisexual girls, who were combined in the study (n 5 59), were found to be more content with their bodies and less likely to report trying to look like images of women in the media than were heterosexual girls. On the other hand, the study found that gay and bisexual boys, also combined in the study (n 5 38), were more likely than heterosexual boys to report trying to look like images of men in the media (Austin et al., 2004b). In another study, using the 1998–2005 waves of the Growing Up Today Study (n 5 13,795), youth who described themselves as lesbian/gay, bisexual, and “mostly” heterosexual had higher rates of binge eating than their heterosexual peers, and all subgroups with the exception of lesbians had higher rates of purging (vomiting and/or using laxatives to control weight) throughout adolescence (Austin et al., 2009a). While these are provocative findings, they come from only two studies; more research is required to either confirm or refute them. Additionally, if these findings are accurate, more research is needed to understand the mechanisms that put these youth at increased risk for eating disorders. Results of one study using data from the 1995 and 1997 waves of the Vermont (n 5 14,623) and Massachusetts (n 5 8,141) Youth Risk Behavior Surveys suggest that youth who reported having sex with both males and females were at greatest risk for a variety of problem behaviors, including

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151 CHILDHOOD/ADOLESCENCE disordered eating. In Vermont, 25.6 percent of youth with sexual partners of both sexes reported using unhealthy weight control practices, compared with 12.3 percent of those with exclusively same-sex sexual partners and 7.1 percent of those with exclusively opposite-sex sexual partners. In Mas- sachusetts these practices were reported by 37.4 percent of students with sexual partners of both sexes, compared with 15.3 percent of those with ex- clusively same-sex sexual partners and 7.0 percent of those with exclusively opposite-sex sexual partners. This study was based on sexual behavior, not identity (Robin et al., 2002). The literature on eating disorders among LGBT youth is based on large data sets, unlike most of the literature on these populations, which often relies on small convenience samples. However, the research on eating disorders in these populations is still sparse. Transgender-Specific Mental Health Status DSM-IV includes diagnoses of gender identity disorder for children as well as for adolescents (and adults) (American Psychiatric Association, 2000b). The criteria for diagnosis of childhood gender identity disorder are listed in Box 4-1. This diagnosis has been controversial, particularly when applied to children. One objection raised is that including this phenomenon as a psychiatric diagnosis identifies gender-variant identity and expression as pathological, even though many gender-variant children do not report emotional distress; rather, distress may be related to the reaction of the social environment to the child’s gender variance. Also, as noted earlier in this chapter, most children with gender-variant expression do not develop an adolescent or adult transgender identity (Wallien and Cohen-Kettenis, 2008), and many adults with a transgender identity do not report symptoms of childhood gender identity disorder (Lawrence, 2010). More specifically, this diagnosis has been criticized for conflating gender-variant expression with gender-variant identity. At least four of the five criteria are required to qualify for the diagnosis, and only one of these explicitly refers to cross- gender identification, allowing children with gender-variant expression but without a variant gender identity to qualify for the diagnosis (see also Bockting and Ehrbar, 2006). The approach to treatment of gender identity disorder among chil- dren includes early therapeutic interventions with the child, and perhaps with the family, school, and/or community, to broaden the child’s gender role interests and behavior and/or provide a safe environment to allow gender identity to develop while preventing rejection, ridicule, and abuse from peers (Benestad, 2009; Brill and Pepper, 2008; Menvielle and Tuerk, 2002; Meyer-Bahlburg, 2002; Rosenberg, 2002; Zucker, 2008). The ap- proach to treatment of gender identity disorder among adolescents includes

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