Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.
Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:
Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.1
Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.2
Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.3 This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.
Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.
Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.4 However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.
Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,5 but don’t forget that young lesbian women may have had sex with men.
Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.6 Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.
Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.
Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.
Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.7
Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,8 because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.9
So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.
The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:
• Ask, “Are your sexual partner’s male, female, or both?”
• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”
• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”
• Ask, “Have you ever had an STI, and if so, how was it treated?”
• Ask, “What do you use for birth control?” either hormonal or barrier methods.
In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.
Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”
By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.
Here are some resources on sex and relationships in LGBT youth:
• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.
• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.
• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.
References
2. National Transgender Discrimination Survey: Full Report. 2012 .
3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133 .
4. J Youth Adolesc. 2015 Jan;44(1):211-24 .
5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7 .
6. Sex Transm Dis. 2010 May;37(5):335-9 .
7. Sexpress: The Toronto teen survey report. 2009 .
8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.
9. Can J Hum Sex. 2008;17(3):123-139 .
Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.
