By Anita Brakman, MS
Senior Director of Education, Research & Training
Physicians for Reproductive Health
New York City
Taylor Rose Ellsworth, MPH
Manager, Education, Research and Training
Physicians for Reproductive Health
New York City
Melanie Gold, DO, DABMA, MQT, FAAP, FACOP
School-Based Health Centers
New York-Presbyterian Hospital
Columbia University Medical Center
New York City
The United States has seen significant advances in rights for lesbian and gay populations this summer, with the Supreme Court’s decision affirming same-sex marriage nationwide. As we celebrate this victory, however, we remain aware of the many challenges still facing lesbian, gay, and bisexual populations, including health disparities. Many such disparities affect youth, especially in the areas of sexual and reproductive health.
For example, new research reports that lesbian, gay, and bisexual (LGB) youth are nearly twice as likely as their heterosexual peers to experience an unintended pregnancy.1 This current study has limitations in that it was not able to separate bisexual students from gay or lesbian students.
The study, published in the American Journal of Public Health, analyzed data from the 2005, 2007, and 2009 New York City Youth Risk Behavior Surveys and examined sexual orientations as well as sexual behaviors of nearly 10,000 sexually active high school students.1
The study found 23% of lesbian or bisexual female students experienced a pregnancy, compared to 13% of heterosexual female students. Looking at behaviors, rather than reported orientation, 20% of female students who reported sexual activity with males and females experienced a pregnancy. Pregnancy was reported by 14% of female students who reported sex only with males.1
The study also assessed involvement in pregnancy among male students. Ten percent of males who reported only female partners or who identified as heterosexual had been involved in a pregnancy. Twenty-nine percent of gay or bisexual males and 38% of males reporting sexual activity with males and females had a pregnancy with a past or current partner. Students of all genders who reported exclusively same-sex sexual behaviors were excluded from the data.1
Similar findings have been reported before, but only in studies that were limited in sample size and/or only included female participants.2,3 None of these studies assessed pregnancy risk among gender non-conforming or transgender youth.
There are a variety of factors, behaviorally and socially, that lead LGB youth to be at increased risk for unintended pregnancy. Overall, LGB youth are likely to initiate sexual intercourse at an earlier age than their peers, have more sexual partners, and are less likely to use effective methods of contraception.4-6 All of these factors contribute to pregnancy risk. These populations also are over-represented among homeless and street-involved youth, which puts them at risk for sexual assault or for survival sex.5
Stigma, and negative coping strategies for dealing with stigma, also contribute to increased risk-taking behaviors for LGB youth. Harassment, discrimination, and sexual or physical violence at home, school, or in the community might all be present in the lives of LGB youth and are sometimes referred to as “enacted stigma.”7 Some youth might deal with enacted stigma through “camouflage” behaviors or having sex and/or relationships with partners of the opposite gender to hide same-sex sexual behaviors or attraction. Others might use or abuse alcohol or drugs. Both of these behaviors put LGB youth at further risk of poor health outcomes, including unintended pregnancy.7
Additionally, sexuality education programs, especially those based in “abstinence only” models, often ignore and sometimes denigrate LGB youth instead of educating them on how to protect themselves against pregnancy and sexually transmitted infections.8
Even so, many LGB youth lead healthy, productive lives and develop resilient adaptations to social biases and stigma. Effects of discrimination also can be mitigated by social support and family acceptance.9
Healthcare providers have a unique opportunity to educate LGB youth, and all adolescent patients, about contraception and other safer sex practices to protect themselves and their partners. Offering information about emergency contraception (EC) might be especially helpful if youth are not anticipating sex with partners that might result in pregnancy.
Some forms of EC are available over the counter and can be purchased by males or females, regardless of age. Female adolescents also can receive an advanced prescription for ella, a form of EC shown to be consistently effective in preventing pregnancy for five days after unprotected sex. Condoms remain the only method for protection against sexually transmitted infections and should be offered to all adolescents of all sexual identities.
Data showing that LGB youth are at increased risk of pregnancy re-affirm the need to take a detailed sexual history of all adolescents and offer them information and services based on their individual risk behaviors, rather than their sexual orientation. Opening up discussions about sexual behaviors also creates the opportunity to discuss relationships and healthy decision-making strategies more broadly.
Lindley LL, Walsemann KM. Sexual orientation and risk of pregnancy among New York City high-school students. Am J Public Health 2015; 105(7):1379-1386.
Saewyc EM, Bearinger LH, Blum RW, et al. Sexual intercourse, abuse and pregnancy among adolescent women: Does sexual orientation make a difference? Fam Plann Perspect 1999; 31(3):127-131.
Saewyc EM, Pettingell SL, Skay CL. Teen pregnancy among sexual minority youth in population-based surveys of the 1990s: Countertrends in a population at risk. J Adolesc Health 2004; 34:125-126.
Tornello SL, Riskind RG, Patterson CJ. Sexual orientation and sexual and reproductive health among adolescent young women in the United States. J Adolesc Health 2014; 54(2):160-168.
McBride DL. Homelessness and health care disparities among lesbian, gay, bisexual, and transgender youth. J Pediatr Nurs 2012; 27(2):177-179.
Garofalo R, Wolf RC, Kessel S, et al. The association between health risk behaviors and sexual orientation among a school-based sample of adolescents. Pediatrics 1998; 101(5):895-902.
Saewyc EM, Poon CS, Homma Y, et al. Stigma management? The links between enacted stigma and teen pregnancy trends among gay, lesbian, and bisexual students in British Columbia. Can J Hum Sex 2008; 17(3):123-139.
Santelli JS, Ott MA, Lyon M, et al. Abstinence and abstinence-only education: A review of U.S. policies and programs. J Adolesc Health 2006; 38(1):72-81.
Garofalo R, Katz E. Health care issues of gay and lesbian youth. Current Opin Pediatr 2001; 13:298-302.