With growing visibility, there is an increasing prevalence of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) youth who feel empowered to own their true identity. Members of the oral health team frequently do not receive sufficient education in their training to recognize the nuance that treating this population may require. Although the tooth-level treatment does not materially change, a deeper appreciation of development of sexuality and gender identity, transgender medicine, and the health disparities LGBTQ+ youth face can promote more meaningful, trusting clinical relationships with this vulnerable population. This article aims to provide members of the oral health team with the requisite knowledge to deliver culturally competent care to LGBTQ+ youth.
Key points
- •
An increasing prevalence of LGBTQ+ youth accentuates the need for oral health providers to have a deeper understanding of the etiology and implications of sexuality and gender development.
- •
LGBTQ+ youth face a number of health disparities that impact both oral and overall health.
- •
There are nuances to treating LGBTQ+ youth that can improve the oral health care experience for this vulnerable population.
Introduction
With increasing visibility, individuals who are lesbian, gay, bisexual, transgender, queer, intersex, two-spirited, or something else (LGBTQ+) are more empowered to publicly identify this way, particularly among younger generations. Current estimates from national surveys indicate that roughly 9% of United States (US) youth aged 13 to 17 years identify as lesbian, gay, or bisexual (LGB) and 0.73% identify as transgender. Despite the trend to more freely express diverse sexual orientations and gender identities, LGBTQ+ individuals of all ages continue to experience misconceptions, discrimination, and widespread health disparities.
Dental and allied oral health educational programs provide inadequate training on these topics, generally relegating the discussion to review pathologies that may be prevalent in this population without presentation of other pertinent characteristics. However, a deeper understanding of LGBTQ+ youth can improve the overall health care experience for these patients, their families, and their providers. Therefore, this review intends to provide background information on sexuality and gender development, an overview of transgender medicine, LGBTQ+ health disparities, and the implications for oral health care.
Development of sexual orientation and gender identity
Development of Sexual Orientation
Sexual orientation refers to one’s pattern of romantic, emotional, and physical attractions and their relation to the gender(s) of the person to whom they are attracted to ( Fig. 1 ). Sexual identity development, similar to gender identity development, is discovered over time. There are multiple dimensions to one’s sexuality that minimally include attraction, interest, orientation, and behaviors. The sexual and romantic aspects of this may also be different from each other within the same individual. Awareness of attraction is often first observed or tends to occur in early adolescence, which is around age 9 for those assigned female at birth and around 10 for those assigned male at birth. Youth who identify as anything other than heterosexual may experience this attraction later. This phase of young adulthood includes becoming aware of these parts of their identity via attraction, fantasies, and behavior. In addition, this age group has more concrete thinking, discomfort with their developing body changes from puberty, and interest in exploring some sexual behaviors.
Adolescents’ uncertainty about their sexual orientation decreases with age, from 26% of 12-year-old students to 5% of 17-year-olds. Approximately 5% to 10% of teens identify as LGB. However, over 10% of females and between 2% and 6% of males report having participated in same-gender sexual activity.
Development of Gender Identity
Gender identity is one’s inner sense of their gender, which may or may not match the sex assigned at birth. Sex assigned at birth is a designation primarily made on visual inspection of external genitalia. When these 2 align, one is cisgender. When they do not align, one is transgender. Gender identity is often thought to exist on a spectrum between the binary poles of male and female, but more likely, gender identity exists in more of a cloud. There are many ways that a person can identify with regard to their gender.
- •
Most common gender identities are male and female.
- •
Other common gender identities are nonbinary, genderqueer, and agender.
- •
Additional gender identities exist and are personal to each individual.
Gender identity is a normal part of childhood development and occurs through several time points.
Birth to age five
In the earliest stage, children commonly explore their gender by looking at their bodies and comparing them to other children. They also observe how adults act with one another and how they treat children based on gender. During this time, children will often try out different gender expressions by dressing up in clothes that may not match their gender assignment. Parents may be concerned or confused when this occurs; however, this is normal and does not necessarily correlate with their adult gender identity. This behavior should simply be treated as play. A small minority of transgender children present at this age. These children are very consistent, persistent, and insistent that their gender was assigned incorrectly. The longer this insistence continues, the more likely that the child will continue to identify as transgender as an adult.
Age five to onset of puberty
From age 5 until the onset of puberty, gender exploration is typically more quiescent. Generally, puberty begins around age 9 in those assigned female at birth and 11 and a half in those assigned male at birth. Pubertal onset and sex hormone production serves as a trigger for robust gender and sexual identity development. Sometimes, these 2 distinct identities may be confused, and one such adolescent may require time to sort them out. At this stage, a small subset of youth may develop gender dysphoria, defined as a significant discomfort with the lack of alignment between their assigned gender and their gender identity. Should more time for exploration be necessary, it is possible to pause puberty using gonadotropin-releasing hormone (GnRH) antagonists to allow further understanding of their true identity. , The GnRH antagonists leuprolide and histrelin help by temporarily halting development of secondary sexual characteristics, such as breast development or body hair growth, among others. Placing a pause on puberty can facilitate avoiding surgery such as a mastectomy as an adult. Additional benefits include relieving gender dysphoria, improving quality of life, and reducing anxiety, depression, self-harm, and suicidal ideation. There can be a transient decrease in bone density while on GnRH antagonists, but this normalizes or stabilizes after the addition of gender-affirming hormones or discontinuing the GnRH antagonist.
Puberty
Puberty can be unpaused without any long-term consequences. If the youth no longer identifies as transgender, simply removing the suppressant will allow their endogenous pubertal axis to proceed as normal. However, if they persist in their identification as transgender, then they can continue on to gender-affirming hormones at the appropriate time for a typical “late bloomer.”
After puberty
Most transgender youth present in late puberty or late adolescence. Still others may not come out until they are much older. In this case, these individuals would bypass GnRH antagonists and initiate gender-affirming hormones should they choose to hormonally transition. Consolidation of gender identity occurs in late adolescence. There may be some changes that are minor after that time with regard to expression or nuances in identity, but it is highly unlikely for someone to identify as cisgender if they have identified as transgender at this stage of development.
Sexual orientation, sex assigned at birth, and gender identity are often confused. The Gender Unicorn ( Fig. 1 ), helps to illustrate their definition and how these are related to each other.
Transgender Youth and Transitioning: Stages and Types of Transition
Although understanding of one’s identity continues throughout life, a person’s understanding of their gender identity is generally stable after adolescence. This does not mean that people only truly are transgender if they transition or come out in adolescence as there are many reasons that person may not transition until later in life. Transitioning and gender affirmation allows transgender individuals to live life according to their internal sense of gender and ultimately decreases anxiety and depression. There are 3 distinct phases of the transition process, and individuals may elect to participate in all, some, or none of these phases.
Social transition
The first, and completely reversible, phase of transition is often a social transition. It can include a number of changes that are culturally specific regarding typical gender expression. In the United States, for example, it is common for boys to have short hair, wear plain pants and shirts, and avoid nail polish and makeup. Girls, on the other hand, frequently have long hair, wear bright or ornamental clothing, and are interested in cosmetics. Thus, an individual assigned male at birth identifying as a girl may grow their hair out and opt for dresses at school. These decisions about outward presentation may change over time. In addition to changes in appearance, the social transition may include selection of a different name and pronouns.
Sometimes social transitioning occurs before the medical transition, other times it occurs concurrently. What matters for most youth is that the provider asks about their personal perspective, experience, and what terminology best suits their needs.
Medical transition
Medical transition is when a person uses gender-affirming hormones that match their gender identity to better match that identity physically. This is a very effective method of improving alignment between body and identity and leads to relief of dysphoria and related depression and anxiety. Overall improvement in quality of life, depression, and anxiety is nearly 80% with this process.
It is important to keep in mind the patient is on these medications and how they may or may not interact with any medications or procedures in your office. In general, the goal is to keep the hormone levels in the normal physiologic range for the gender they identify with and thus should not cause much interference. If there are questions or concerns, the dental team should feel empowered to engage with medical providers to ensure the best treatment for the transgender child, similar to any other patient with a health condition that may be affected by their dental procedures. Some of the relevant reported potential side effects of these medications are described in Table 1 . No long-term adverse dental or oral outcomes are currently reported in the literature secondary to gender-affirming hormone use.
| Medications | Side effects |
|---|---|
| Estrogens |
|
| Androgen blockers (eg, spironolactone) |
|
| Androgens (eg, testosterone) |
|
Surgical transition
Surgical transition is another method that a person who is transgender can use to better align their bodies with their gender identity. There are several procedures that can be done:
- •
For transgender women:
- a.
Facial feminization
- b.
Tracheal shave
- c.
Vocal fold procedures
- d.
Vaginoplasty
- e.
Penectomy
- f.
Orchiectomy
- g.
Breast augmentation
- a.
- •
For transgender men:
- a.
Mastectomy
- b.
Metoidoplasty
- c.
Phalloplasty
- d.
Hysterectomy with or without complete oophorectomy
- e.
Vaginectomy
- a.
These are very rarely performed in individuals younger than 18 years in the United States, although the age of consent varies elsewhere. Not all transgender individuals have a surgical transition because not everyone needs these procedures to feel comfortable with their bodies. Furthermore, they are expensive and often not covered by insurance. Some of these procedures are rather complex with a higher rate of complications than others which may serve as a reason one may not elect to have them. Additionally, local surgeons may not have expertize in these procedures which contributes to a long waitlist for those who do.
Other than understanding how a person tolerated anesthesia or if you are doing a procedure where a urinary catheter might need to be placed, it is unlikely that knowing whether a patient has had one of these procedures would be pertinent to delivering dental care. Asking too many questions about a person’s transition surgeries when they are not relevant is unnecessary and should be avoided.
LGBTQ+ Youth Health Disparities
Health disparities within the LGBTQ+ community are well-documented in literature. Research has demonstrated many possible reasons for these disparities: financial barriers to health care, difficulty finding affirmative providers, lack of social network and support, as well as lifetime victimization. The Minority Stress Model is the leading explanatory theory for sexual orientation–related health disparities and suggests that members of a minority population experience persistent stress related to their sexual orientation.
Minority stress may lead to poorer health through anticipated discrimination, actual experiences with prejudicial events, and internalized stigma. Anticipated discrimination refers to the expectation of being marginalized as a consequence of social stigma or past negative encounters in health care settings. Actual discrimination refers to the lived experience of LGBTQ+ individuals and can include situations such as health care providers making homophobic or transphobic comments or failing to recognize same-sex partners as family members. , Transgender people often delay seeking care and express distress with disclosing their gender identity to their provider. Avoidance of health care, in part, may be attributed to internalized stigma. The way in which LGBTQ+ people experience discrimination may result in accepting the negative attitude toward them and choosing to avoid care.
Ignorance around LGBTQ+-related health is another barrier preventing people from accessing care. Many LGBTQ+ people report being unable to discuss health issues that relate to their sexual orientation as a result of obvious displays of discomfort by their care providers. According to the 2015 US Transgender Survey, 24% of respondents reported having to teach their provider about transgender people to receive appropriate care. Several studies have illustrated the frustration and concerns transgender patients have with mental health professionals and their determination of eligibility for gender-confirming surgery. There are insufficient data to support that health care professionals are adequately trained to provide appropriate care to the trans and nonbinary community.
With the increasing prevalence of individuals identifying as trans and nonbinary, barriers to seeking transgender-related health care are slowly improving. Government health care programs (eg, Medicaid, Medicare) and private insurance plans have started to incorporate coverage for gender-affirming care and surgery. However, many transgender and nonbinary individuals avoid seeking health care because of poor experiences. These have included insensitivity to one’s gender identity, awkward interactions believed to be related to gender identity, refusal of care, substandard care, verbal abuse, and being forced to seek psychiatric treatment.
Despite analyzing LGBTQ+ health disparities through federally funded health surveys, most do not gather information on gender identity. Thus, obtaining information regarding transgender health is difficult, particularly as it pertains to transgender youth. It is understood, however, that transgender and nonbinary individuals have a higher odds of reporting poor physical and mental health relative to their cisgender counterparts. They are often victim to various forms of stigma, discrimination, and exclusion in public settings and, as a consequence, experience high levels of psychological distress. A history of antitransgender violence, or fear of it, may prevent an individual from seeking medical care.
The discrimination faced by LGBTQ+ youth may lead to an array of negative physical and mental health disorders. LGBTQ+ people often report being victim to verbal harassment and feeling unwelcome because of their sexual orientation and/or gender identity. Depression and suicidal ideation or attempts are common sequelae of such marginalization. LGBTQ+ youth are more likely than their cisgender and heterosexual counterparts to die by suicide related to the homophobia, biphobia, and transphobia they may experience in society. Exclusion from society often includes parental rejection too. Approximately 30% to 45% of LGBTQ+ youth experience homelessness, which has also been associated with higher rates of mental health disorders and suicidality. Homelessness makes obtaining care of any type, particularly preventive, difficult because of both cost and access.
Already faced with an array of mental health issues, the COVID-19 pandemic placed LGBTQ+ youth in a difficult situation, with some reporting difficulty being isolated with an unsupportive or unsafe family, removed from critical social connections, and less access to support staff and necessary medical care. , Online versions of real-time chat or voice counseling sessions have proven helpful for those who had access during quarantine. ,
LGBTQ+ adolescents are more likely to engage in risky conduct, including substance use and abuse, tobacco smoking, and high-risk sexual behaviors. , They report a greater number of drinking days and heavy drinking episodes than their heterosexual, cisgender counterparts. Tobacco use for LGB people is approximately twice as high compared with heterosexuals. There are several risk-enhancing variables attached to this: being single, reporting more poor mental health days, excessive drinking, life dissatisfaction, low income, barriers to health care, unemployment, and so forth. These behaviors are more associated with less-affirmative communities and schools.
LGBTQ+ youth, especially men who have sex with men, show a high incidence of sexually transmitted diseases that can be attributed to earlier onset in sexual experiences, increased number of sexual encounters with multiple partners, and poor education on safe sex practices. According to the Center for Disease Control and Prevention data from 2018, gay and bisexual men comprised 69% of new HIV diagnoses for those aged 13 years and older. The 2015 US Transgender Survey found the prevalence of HIV infection to be 5 times greater for trans and nonbinary individuals relative to the general population.
Minimal research is available on oral health–specific disparities related to the LGBTQ+ community. One study noted an increased prevalence in oral human papilloma virus-positive status among gay and lesbian individuals relative to bisexual and heterosexual individuals. Moreover, LGB individuals reported higher prevalence of fair or poor oral health. Another study showed transgender adults to be less likely to have visited the dentist in the past year compared to cisgender adults. Trans and nonbinary people exhibit higher levels of dental fear as well. Fortunately, transgender adolescents and young adults aged 14 years through 24 years have reported positive experiences with their oral health providers. More oral health research is needed to properly assess the oral health status of LGBTQ+ youth.
Considerations for LGBTQ+ Youth in the Dental Setting
Dentists and allied providers receive limited training on LGBTQ+ health-related needs during formal training. One survey found 29% of participating US and Canadian dental schools reporting not covering LGBTQ+-related topics. Another study revealed that only 13.3% of dental students felt adequately equipped to treat LGBTQ+ patients, which may be the result of minimal exposure in their clinical training. , Dental professionals who feel prepared, by their formal education, to treat people of diverse backgrounds are more likely to treat these patients in their communities. Often, what is taught in dental curricula on LGBTQ+ people surround themes such as sexually transmitted diseases or substance use and abuse. This information may be presented in a way that not only lacks discussion on how to address disparities with cultural competence but also further stigmatizes these populations. Fortunately, there are several evidence-based best practices when working with LGBTQ+ patients.
One challenge faced by caregivers of LGBTQ+ youth is finding accepting providers. Some may rely on social media or word-of-mouth to ascertain welcoming practices, while others are looking for indications on websites, promotional materials, or within the office. Items such as a Safe Space sticker, pride flags or decals, and inclusive photos or magazines can all be ways to indicate the practice is welcoming to LGBTQ+ youth. Caregivers of transgender youth report carefully reviewing office nondiscrimination policies for protected terms such as “sexual orientation” and “gender identity.” Inclusive language for intake forms and while conversing are important drivers of a positive health care experience. ,
Intake and medical history forms with considerate and inclusive language can be the first sign of a welcoming practice. This includes detailed inquiries on gender identity, name, and pronoun preferences. A two-step method for identifying noncisgender individuals has been proposed, recording both the sex assigned at birth and the gender identity. This way of collecting information has proven to be effective, as it takes into account the biological (ie, gender assigned at birth) and social (ie, gender identity) constructs.
It is vital for practitioners to be familiar with gender identities that extend beyond the traditional binary view. LGBTQ+ youth may have preferred pronouns correlating with their gender identity and not sex assigned at birth, thus making it important to also ask patients when obtaining a medical history. , Patients report greater satisfaction and less anxiety when they are addressed by their preferred name and pronouns. Dentists are strongly encouraged to revise their intake forms to better reflect the needs of all genders and sexualities. An example of an inclusive intake form can be seen in Fig. 2 .
